Loria, Barbara E. Millen, Cathy A. Nonas, F. Xavier Pi-Sunyer, June Stevens, Victor J. Stevens, Karen A. Donato, Frank B. Hu, Van S. Hubbard, John M. Jakicic, Robert F. Kushner, Catherine M. Michael D. Jensen, Donna H. Ryan, Caroline M. Apovian, Jamy D. Ard, Anthony G. Comuzzie, Practice Guidelines and The Obesity Society Report of the American College of Cardiology/American Heart Association Task Force on 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2013 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation published online November 12, 2013; Circulation. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.citation World Wide Web at: The online version of this article, along with updated information and services, is located on the http://circ.ahajournals.org/content/suppl/2013/11/07/01.cir.0000437739.71477.ee.DC1.html Data Supplement (unedited) at:

/pdf/2013-aha-acc-tos-guideline-for-the-management-of-overweight-3w1saiwrmy.pdf

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

CONTEXT: Early intensive behavioral and developmental interventions for young children with autism spectrum disorders (ASDs) may enhance developmental outcomes. OBJECTIVE: To systematically review evidence regarding such interventions for children aged 12 and younger with ASDs. METHODS: We searched Medline, PsycINFO, and ERIC (Education Resources Information Center) from 2000 to May 2010. Two reviewers independently assessed studies against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes and assigned overall quality and strength-of-evidence ratings using predetermined criteria. RESULTS: Thirty-four unique studies met inclusion criteria. Seventeen studies were case series; 2 were randomized controlled trials. We rated 1 study as good quality, 10 as fair quality, and 23 as poor quality. The strength of the evidence overall ranged from insufficient to low. Studies of University of California Los Angeles/Lovaas–based interventions and variants reported clinically significant gains in language and cognitive skills in some children, as did 1 randomized controlled trial of an early intensive developmental intervention approach (the Early Start Denver Model). Specific parent-training approaches yielded gains in short-term language function and some challenging behaviors. Data suggest that subgroups of children displayed more prominent gains across studies, but participant characteristics associated with greater gains are not well understood. CONCLUSIONS: Studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvements in cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs, although the literature is limited by methodologic concerns.

A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders

Raising a child with an autism spectrum disorder (ASD) can be an overwhelming experience for parents and families. The pervasive and severe deficits often present in children with ASD are associated with a plethora of difficulties in caregivers, including decreased parenting efficacy, increased parenting stress, and an increase in mental and physical health problems compared with parents of both typically developing children and children with other developmental disorders. In addition to significant financial strain and time pressures, high rates of divorce and lower overall family well-being highlight the burden that having a child with an ASD can place on families. These parent and family effects reciprocally and negatively impact the diagnosed child and can even serve to diminish the positive effects of intervention. However, most interventions for ASD are evaluated only in terms of child outcomes, ignoring parent and family factors that may have an influence on both the immediate and long-term effects of therapy. It cannot be assumed that even significant improvements in the diagnosed child will ameliorate the parent and family distress already present, especially as the time and expense of intervention can add further family disruption. Thus, a new model of intervention evaluation is proposed, which incorporates these factors and better captures the transactional nature of these relationships.

Parent and Family Impact of Autism Spectrum Disorders: A Review and Proposed Model for Intervention Evaluation

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnosticcriteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child’s function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions.  This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder.

Objective  To provide an overview of prediction models for risk of cardiovascular disease (CVD) in the general population. Design  Systematic review. Data sources  Medline and Embase until June 2013. Eligibility criteria for study selection  Studies describing the development or external validation of a multivariable model for predicting CVD risk in the general population. Results  9965 references were screened, of which 212 articles were included in the review, describing the development of 363 prediction models and 473 external validations. Most models were developed in Europe (n=167, 46%), predicted risk of fatal or non-fatal coronary heart disease (n=118, 33%) over a 10 year period (n=209, 58%). The most common predictors were smoking (n=325, 90%) and age (n=321, 88%), and most models were sex specific (n=250, 69%). Substantial heterogeneity in predictor and outcome definitions was observed between models, and important clinical and methodological information were often missing. The prediction horizon was not specified for 49 models (13%), and for 92 (25%) crucial information was missing to enable the model to be used for individual risk prediction. Only 132 developed models (36%) were externally validated and only 70 (19%) by independent investigators. Model performance was heterogeneous and measures such as discrimination and calibration were reported for only 65% and 58% of the external validations, respectively. Conclusions  There is an excess of models predicting incident CVD in the general population. The usefulness of most of the models remains unclear owing to methodological shortcomings, incomplete presentation, and lack of external validation and model impact studies. Rather than developing yet another similar CVD risk prediction model, in this era of large datasets, future research should focus on externally validating and comparing head-to-head promising CVD risk models that already exist, on tailoring or even combining these models to local settings, and investigating whether these models can be extended by addition of new predictors.

https://www.bmj.com/content/bmj/353/bmj.i2416.full.pdf

Prediction models for cardiovascular disease risk in the general population: systematic review

Review Form First Author, Year: ___________________ Ref ID #__________ Abstractor Initials: ___ ___ ___ Primary Inclusion/Exclusion Criteria 1. Relevant to SER topic Yes No Cannot Determine 2. Attempts internal or external validation Yes No Cannot Determine 3. Published in English Yes No Cannot Determine 4. Original research (exclude reviews, editorials, commentaries, letters to editor, etc.) Yes No Cannot Determine 5. Eligible Study types a. Randomized controlled trials b. Controlled clinical trials

Systematic Review of Cardiovascular Disease Risk Assessment Tools

Objectives The Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for children ages 2 to 12 with autism spectrum disorders (ASDs). We focused on treatment outcomes, modifiers of treatment effectiveness, evidence for generalization of outcomes to other contexts, and evidence to support treatment decisions in children ages 0–2 at risk for an ASD diagnosis. Data We searched MEDLINE,® ERIC, and PsycInfo.® Review Methods We included studies published in English from January 2000 to May 2010. We excluded medical studies with fewer than 30 participants; behavioral, educational, and allied health studies with fewer than 10 participants; and studies lacking relevance to treatment for ASDs. Results Of 159 unique studies included, 13 were good quality, 56 were fair, and 90 poor. The antipsychotic drugs risperidone and aripiprazole demonstrate improvement in challenging behavior that includes emotional distress, aggression, hyperactivity, and self-injury, but both have high incidence of harms. No current medical interventions demonstrate clear benefit for social or communication symptoms in ASDs. Evidence supports early intensive behavioral and developmental intervention, including the University of California, Los Angeles (UCLA)/Lovaas model and Early Start Denver Model (ESDM) for improving cognitive performance, language skills, and adaptive behavior in some groups of children. Data are preliminary but promising for intensive intervention in children under age 2. All of these studies need to be replicated, and specific focus is needed to characterize which children are most likely to benefit. Evidence suggests that interventions focusing on providing parent training and cognitive behavioral therapy (CBT) for bolstering social skills and managing challenging behaviors may be useful for children with ASDs to improve social communication, language use, and potentially, symptom severity. The Treatment and Education of Autistic and Communication related handicapped CHildren (TEACCH) program demonstrated some improvements in motor skills and cognitive measures. Little evidence is available to assess other behavioral interventions, allied health therapies, or complementary and alternative medicine. Information is lacking on modifiers of effectiveness, generalization of effects outside the treatment context, components of multicomponent therapies that drive effectiveness, and predictors of treatment success. Conclusions Medical interventions including risperidone and aripiprazole show benefit for reducing challenging behaviors in some children with ASDs, but side effects are significant. Some behavioral and educational interventions that vary widely in terms of scope, target, and intensity have demonstrated effects, but the lack of consistent data limits our understanding of whether these interventions are linked to specific clinically meaningful changes in functioning. The needs for continuing improvements in methodologic rigor in the field and for larger multisite studies of existing interventions are substantial. Better characterization of children in these studies to target treatment plans is imperative.

Therapies for Children With Autism Spectrum Disorders

Summary Table 2

Objectives To summarize the current state of cardiovascular disease (CVD) risk modeling literature with a focus on the U.S. patient population, and to describe evidence on which models best predict cardiovascular risk among patients with diabetes. Data Sources We searched MEDLINE for articles published January 1, 1999, to February 24, 2009, and reviewed all reference lists of included articles. Review Methods We included studies of asymptomatic adults in any geographic setting with any study design in which a CVD clinical risk prediction model was developed or validated. We excluded studies that 1) were not in English; 2) were without information pertinent to the key questions; 3) had fewer than 200 participants at enrollment; 4) were not original studies; and 5) lacked internal or external validation data. We captured study information such as cohort characteristics, risk model characteristics, model performance statistics, and quality review elements. We collected information about the study populations for stratification of results by variables, including sex and geographic area. We also searched online for available tools and documented their location and the model on which they purported to be based. We used the online tools to calculate risk for five test cases to identify variation in estimated risk. Results Of the 3,499 articles initially identified, 84 met inclusion criteria, providing data on 102 risk models. The majority of models (87 out of 102) were not externally validated. The most commonly externally validated risk models were the 1991 Framingham (FRS) model for CVD (26 evaluations), the 1998 FRS model for total coronary heart disease (CHD) (24 evaluations), the FRS Adult Treatment Panel III (ATP-III) model for hard CHD (16 evaluations), the Prospective Cardiovascular Munster (PROCAM) model for hard CHD (11 evaluations), and the Systematic Coronary Risk Evaluation (SCORE) model for CVD mortality (11 evaluations). Conclusion The FRS models performed well in U.S. populations, but there were absolute risk prediction problems when they were applied to populations substantially different from the source cohort. Sometimes this was due to particularly low or high baseline risk in the destination cohort, and at other times to systematic differences in risk attributable to specific factors. The 2001 ATP-III version demonstrated better risk prediction than older FRS models because it focuses on hard CHD outcomes, excludes patients with diabetes, and includes newer FRS data. Diabetes-specific process measurement variables are significantly related to cardiovascular outcome risk among patients with diabetes, and risk models that incorporate these factors outperform general risk prediction models when applied to these patients. Models excluding patients with diabetes outperformed general risk prediction models that included these patients in their development when applied to non-diabetic cohorts. Unfortunately, external validation of diabetes-specific risk models is lacking, particularly among U.S. cohorts.

Allison Glasser

Papers

A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders

Systematic Review of Cardiovascular Disease Risk Assessment Tools

Therapies for Children With Autism Spectrum Disorders

Summary Table 2

Systematic Review of Cardiovascular Disease Risk Assessment Tools [Internet]