Grandin T womens health 40 buy femara 2.5mg with mastercard, American Meat Institute Animal Welfare Commit straining and bodygripping traps for development of best tee 45 menstrual cycle buy femara 2.5 mg fast delivery. Recommended animal handling guidelines and audit management practices for trapping in the United States breast cancer zippo lighter cheap femara 2.5 mg on-line. Solving returntosensibility problems after elec for lynx (Felis lynx): the Conibear 330 with clamping bars breast cancer jersey discount femara 2.5 mg online. Studies on the return of physical refexes in pigs thresholds for developing standards for possum kill traps menstruation pronunciation discount femara 2.5 mg without a prescription. Assessment of the Kania by cardiac arrest electrical stunning is an effective alter trap to humanely kill red squirrels (Tamiasciurus hudsoni native to headonly electrical stunning in pigs women's health clinic orangeville purchase femara 2.5 mg fast delivery. The Jarvis Beef Stunner: effect of a magnum and Bionic traps to humanely kill mink (lett) menstrual cycle calendar generic femara 2.5mg on-line. Brussels: the Council of the Eu mal Welfare and World Society for the Protection of Animals menopause genetic buy femara 2.5 mg amex, ropean Union, 2009. Assessment and prelimi inactivation of brain enzyme activity by heating and micro nary development of the rotating jaw Conibear 120 trap wave irradiation. Alabama Department of Conservation and Natural Resourc Cholinergic mechanisms and psychopharmacology. Guidelines of the the microwave magnetic feld for the rapid inactivation of American Society of Mammalogists for the use of wild mam brain enzymes. Review of pression for euthanasia of anesthetized sparrows (Passer mechanical euthanasia of dayold poultry. Differences in behavior between sheep and care and use of agricultural animals in agricultural re cattle during slaughter. Observations on the physiological ef 1099/2009 of 24 December 2009 on the protection of ani fects of pithing cattle at slaughter. Training and mon and Environment itoring of these individuals for profciency vary by setting and state (eg, animal control offcers, animal S1 Companion Animals care technicians in laboratories, certifed euthanasia Methods acceptable with conditions are equiva technicians in shelters in some states), as does the lent to acceptable methods when all criteria for ap amount of veterinary supervision required. This requires an organizational breeding animals (from dams, sires, and single lit commitment to provide ongoing professional train ters to colonies of breeding animals); populations ing on the latest methods and materials available for of animals maintained in animal control facilities, euthanasia and effective management of compas shelters and rescues, and pet shops; and animals sion fatigue for all personnel. Examples of less nel should be familiar with methods of restraint and common venues in which companion animals might euthanasia for all species likely to be encountered in be euthanized include quarantine stations and Grey their facility. Aquatic companion animals are Areas where euthanasia is conducted in institu considered in Section S6, Finfsh and Aquatic Inver tional settings should be isolated from other activi tebrates, of the Guidelines. As indicated previously ties, where possible, to minimize stress on animals in this document (see Section I5. A welldesigned euthanasia space provides their owners or caretakers vary and should be care good lighting with the ability to dim or brighten as re fully considered and respected when selecting an ap quired, ventilation, adaptable fxtures, and adequate proach to euthanasia for these species. At ducted in quiet, familiar environments when prac tempts should be made to minimize smells, sights, tical. The species being euthanized, the reason for and sounds that may be stressors for animals being eu euthanasia, and the availability of equipment and per thanized. Basic equipment for handling and restraint, sonnel will all contribute to decisions about the most a scale, clippers, tourniquets, stethoscope, cleaning appropriate location. The professional judgment of supplies, a variety of needles and syringes, and body the veterinarian conducting or providing oversight bags should be readily available to accommodate the for euthanasia is paramount in making appropriate needs of potentially diverse animal populations. In decisions about euthanasia (eg, location, agent, route of administration) in species kept as companions and addition, a frstaid kit should be available to address in the specifc environments where they are encoun minor human injuries, and medical attention should tered. Personnel conducting euthanasia must have a always be sought for bite injuries and more serious complete understanding of and profciency in the eu human injuries. Euthanasia protocols for companion animals For individually owned companion animals, eu (usually dogs and cats) in institutional settings (eg, thanasia will often be conducted in a private room in shelters, large breeding facilities, research facilities, a veterinary clinic or in the home, to minimize ani quarantine facilities, racetracks) may differ from mal and owner distress. Owners should other equipment, diagnostic and research needs (eg, be fully informed about the process they are about postmortem tissue samples), and the number of ani to observe, including the potential for excitation dur mals to be euthanized. Euthanasia information as to their applicability in frequently en should only be attempted when the necessary drugs countered environments. While protocols may differ, and supplies are available to ensure a smooth proce the interests of the animal must be given equal con dure and, upon verifcation of death, owners should sideration whether the animal is individually owned be verbally notifed. T61 is also not cur Intravenous injection of a barbituric acid derivative rently being manufactured in the United States but is (eg, pentobarbital, pentobarbital combination prod obtainable from Canada. Assurance of death is paramount and may require a second step, such as a barbiturate, or additional S1. If barbiturates are ery, care must be taken to ensure death has occurred not available, its extralabel use in cats is also accept prior to disposing of animal remains. Aesthetically objectionable tious animals prior to administration of an injectable agonal breathing may occur in unconscious animals euthanasia agent. While dis used effectively for euthanasia when required con concerting for observers, because the animal is un ditions for administration (see detailed discussion conscious, agonal breathing has limited impact on its in Inhaled Agents section of the Guidelines) can be welfare. It may be considered in un (unresponsive to noxious stimuli) or under general usual or rare circumstances, such as natural disasters anesthesia. Alternate methods with fewer conditions and bon dioxide is acceptable with conditions for use in disadvantages are recommended whenever feasible. The disadvantages of electrocution outweigh stances, including but not limited to , natural disasters its advantages; therefore it is not recommended for and largescale disease outbreaks. Alternate meth with fewer conditions and disadvantages are recom ods with fewer conditions and disadvantages should mended for companion animals where feasible. A method cause of the limited information available regarding acceptable with conditions, use of gunshot may be their effectiveness and high probability of pain asso appropriate in remote areas or emergency situations ciated with injection in awake animals. Doing so will assist in re trolled laboratory setting has been described as an ef lieving anxiety and pain for the animal, in addition to fective and humane method of euthanasia for rabbits reducing safety risks for personnel. Penetrating captive bolt is not recommended as a routine approach to the euthana sia of dogs, cats, or other small companion animals, S1. The resistance of altricial neonates (eg, sedation or even death of animals that consume the cats, dogs, mice, rats) to euthanasia methods whose body. For this reason safe handling and appropriate mechanisms rely on hypoxia suggests that the uterus disposal of the remains are critically important. Addi should not be opened for substantially longer periods tional information is available in Section I8, Disposal than for precocial neonates, 24 perhaps 1 hour or lon of Animal Remains. Alter via an injection of a barbiturate or barbituric acid natively, general anesthesia may be induced, followed derivative (eg, sodium pentobarbital) as previously by administration of a euthanasia agent. Fetuses should be left undisturbed in the uterus for 15 to 20 minutes after the bitch or queen S1. This guidance is also gener Euthanasia protocols in large breeding facilities ally applicable to nonmammalian species, with eutha may differ from those utilized in a clinical practice set nasia of eggs per guidance provided in the S5, Avians; ting. Indications for euthanasia in breeding facilities S6, Finfsh and Aquatic Invertebrates; and S7 Zoologic include neonates with congenital defects, acquired and FreeRanging Nondomestic Animals sections of abnormalities or diseases within any segment of the the Guidelines. Intraperitoneal injections of pento population, or other conditions that render animals barbital should be avoided whenever possible during unsuitable for breeding or sale. Euthanasia may be the later stages of pregnancy due to the likelihood of performed on an individualanimal basis, or in groups. Re od of euthanasia in preweanling dogs, cats, and small gardless of method and number of animals being eu mammals. Intraosseous injection may also be used, if thanized, procedures must be performed in a profes strategies are used to minimize discomfort from in sional, compassionate manner by trained individuals jection by using intraosseous catheters that may be under veterinary oversight. Appropriate techniques in place (see Section M2, Noninhaled Agents, of the for assuring death must be applied individually, re Guidelines), or if the animal is anesthetized prior to gardless of the number of animals being euthanized. When and tissue collection can also be a critical factor af euthanizing animals that are well socialized without fecting choice of euthanasia method. One indi (eg, bilateral thoracotomy, exsanguination, perfusion vidual restrains the animal and the other administers with fxatives, injection of potassium chloride). Animals used tious animals, a sedative or anesthetic should be ad in infectious disease studies may require special han ministered prior to attempting euthanasia. Be All activities related to the euthanasia of rodents cause of the diversity of animals received by shelters, deserve consideration equivalent to the euthanasia technicians performing euthanasia must have a good method itself, and may factor into the choice of meth understanding of animal behavior and restraint, the od. Activities that contribute to distress in rodents in proper use of equipment, and the variety of euthana 26 clude transport, handling (in animals not accustomed sia drugs available and their effects. Meth has mandatory veterinary input and considers animal ods of euthanasia likely to elicit distress vocalizations welfare, requirements for postmortem tissue speci or pheromones that other animals in the room could mens, and interference of euthanasia agents or meth hear or smell may be best performed in another loca ods with study results. Sim form strong emotional bonds with companion ani ilarly, wildcaught animals should be handled and eu mals in scientifc settings, so sensitivity to grief and compassion fatigue is necessary. Death should be confrmed by physical examination, ensured by adjunctive physical method, or obviated S2 Laboratory Animals 46 by validation of euthanasia chambers and process. Methods acceptable with conditions are equiva lent to acceptable methods when all criteria for ap S2. The euthanasia dose is typically 3 elsewhere in the Guidelines, and usually apply to times the anesthetic dose. Some other commonly used barbiturate for laboratory rodents commonly used laboratory animal species are ad because of its long shelf life and rapidity of action. Venous but the degree of pain and a suitable method for con access in these animals is typically diffcult, and in trolling pain have yet to be defned. Cervical dislocation re understanding that there is potential for increased quires neither special equipment nor transport of the distress due to dyspnea at lower fow rates or mucous animal and yields tissues uncontaminated by chemi membrane pain associated with fow rates at the high cal agents. If handled correctly, rats and mice tings and has been determined to be as aversive as do not show evidence of hypothalamicpituitaryad other inhalants, 52, 66 it is acceptable with conditions as renal axis activation from decapitation or from being present when other rats or mice are decapitated. There are no data to support the use sia of laboratory animals as they are not rapidly act of hypothermia as a single method, and it should be ing, require high doses, and are not true anesthetic followed with a secondary method following loss of agents. It has a slow onset of action but a long pothermia for anesthesia is not recommended after duration of anesthesia. Rat and mouse pups are born cervical region is acceptable with conditions for fetal neurologically immature when compared with hu and neonatal mice and rats. Precocial young should the research goals will often infuence the choice be treated as adults. Appropriate restraint for the species cy to breathhold when confronted with unpleasant must always be applied. In a controlled cation with sedatives may reduce potential aversion setting such as a biomedical research facility where responses. In large commercial production operations for ceptable with conditions for rabbits when performed biomedical research or meat, or to safely euthanize by individuals with a demonstrated high degree of injured wild rabbits, the method selected will de technical profciency. The need for technical compe tency is great in heavy or mature rabbits in which pend on the availability of resources and the skill and the large muscle mass in the cervical region makes training of the operator. Lack of breathing and palpable heartbeat as well to the hips and back legs reduce the strength needed as a fxed dilated pupil are some of the easiest recog by the operator to euthanize rabbits. The captive bolt must be main vices are available, venous access may be obtained via tained in clean working order, positioned correctly the ear. In the case of fractious rabbits, sedation may (by placing the captive bolt slightly paramedian on be necessary to gain venous access for administration 106 the frontal bone as close to the ears as possible), of an injectable barbiturate or injectable barbiturate and operated safely by trained personnel. Barbiturates may also be administered tial to stabilize the head to prevent misses. The concurrent use of local anesthetics and an should be restrained on nonslip fooring, preferably ticonvulsants may aid in prevention of pain, 47 but it in an opentop container allowing the rear of the should be considered that these compounds may also rabbit to be pressed against the container wall. These approaches are ing the nondominant hand, the operator should re acceptable for companion rabbits as well. These devices are of CondItIons methods ten aesthetically displeasing and often result in envi S2. Operators must be trained, preferably on ting, such as a biomedical research facility or vet cadavers. The tional exposure of the fsh to chilled water for times device must be maintained in clean working order, specifc to fsh size and age108, 110, 111 should be used to positioned correctly (center of the forehead, with ensure death. Rapid chilling of adult zebrafsh result the barrel placed in front of the ears and behind the ed in cessation of vital signs (10. Manual application of blunt force trauma to the ensure death of other life stages, rapid chilling may head has been shown to be diffcult and aesthetically be followed by either an approved adjunctive eutha displeasing, resulting in undesired tissue damage, as nasia method or a humane killing method. Amphibian species commonly used in research an injured rabbit too large for the operator to cervi include the African and Western clawed frog (X lae cally dislocate and an operator without any support vis, Xenopus tropicalis), leopard and bull (Rana ing resources. In this sec tion, only the most commonly used methods will be discussed for several frequently used species. Animals Farmed methods less often used for euthanizing species used for Food and Fiber in research are discussed in detail in the relevant sec Methods acceptable with conditions are equiva tions of the Guidelines. See these sections for addi lent to acceptable methods when all criteria for ap tional information. However, because recovery of fsh after domesticated for agricultural purposes, specifcally exposure for this time has been shown to occur, 30 cattle, sheep, goats, swine, and poultry, regardless minutes is recommended as a precautionary measure of the context in which that animal is being kept or until research is available to demonstrate immersion the basis for the decision to euthanize it. Suggestions times needed to reliably cause irreversible death in ze for euthanasia of agricultural animals such as cam brafsh. This is facilitated by en should be selected to have adequate penetration abil suring that facilities are well designed, appropriate ity. Older types of hollowpoint bullets are designed equipment is available, and animal handlers are prop to expand and fragment on impact with their targets, erly trained and their performance is monitored. The most important indicator of death neural tissues; however, because penetration of the is lack of a heartbeat. However, because this may be skull is the frst criterion in euthanasia, a solid lead diffcult to evaluate or confrm in some situations, bullet is preferred. Since the publication of the previ animals can be observed for secondary indicators of ous edition, many new types of bullets and frearms death, which might include lack of movement over are now available. These must be of suffcient muzzle a period of time (30 minutes beyond detection of a velocity to ensure penetration. Rifing imparts stability barbiturates for euthanasia of large numbers of ani to the bullet and improves accuracy. For this reason, mals, these agents tend to be less expensive than oth rifes are the preferred frearm for euthanasia when it er injectable pharmaceuticals. Another reason of barbiturates are that their administration requires a rife is preferred is that a longer barrel may improve adequate restraint of the animal, personnel who are bullet performance. Standard and high ministration of a sedative might be desirable, in some velocity bullets fred from a. Models using gun skull (within 30 to 90 cm [1 to 3 feet]), and 4) the bul powder charges are more often used in farm environ let must be directed so that proper anatomic place ments. A cally designed for shotguns) are appropriate from a series of cushions are strategically located within the distance of 1 to 2 yards (1 to 2 m). Depend guns are lethal at close range, the preferred gauges ing upon model, the bolt may be manually or auto for euthanasia of cattle are 20, 16, or 12. Accurate placement over the ide larger birdshot or shotgun slugs are the best choices al anatomic site, energy (ie, bolt velocity), and depth for euthanasia of cattle. Bolt velocities of 55 to 58 m/s are desirable tics on entry that are similar to a solid lead bullet. In packing sion of birdshot into the brain that results in immedi plants where bolt velocity is of particular concern, ate loss of consciousness and rapid death. Researchers concluded that the rail in a damp location, poor maintenance of fring pins, sighting system on the shotgun was not suffcient for inexperienced personnel operating the captive bolt accurate shot placement if it was necessary to shoot (use of the incorrect anatomic site), misfres associ from a distance. They also believed that recoil from ated with a dirty trigger on the captive bolt, and use this frearm would likely make it unpleasant to use of the device on cows and bulls with thick, heavy if it were necessary to euthanize a large number of skulls. The muzzle should always recommended for euthanasia of mature cattle in be pointed toward the ground and away from the feld situations. Once tant anatomic differences that need to be considered the animal is restrained, discharge of the captive bolt when determining the best method of euthanasia for should occur with little or no delay so that animal water buffalo, compared with cattle. Adjunctive methods should be substantially thicker and the frontal and paranasal implemented as soon as the animal is rendered un sinuses noticeably wider in buffalo, compared with conscious to avoid a possible return to sensibility. Moreover, measures of the median distance Thus, when conducting euthanasia by captive bolt, from the frontal skin surface to the thalamus were some preplanning and preparation improves the like 144. This site would appear each drawn from the outside corner of the eye to the to be similar to sites described in the guidelines for center of the base of the opposite horn, or an equiva domestic cattle.
Restricting the literature to roughly the past decade menstrual 5 days early generic 2.5 mg femara overnight delivery, a common practice in evidencebased reviews women's health center flint mi cheap femara express, ensures that the included articles reflect the most recent work in a field (even though some methodologically rigorous and groundbreaking studies published before or after the cutoff date may not be represented in the review) women's health big book of yoga download purchase femara australia. Additionally lynn women's health center boca raton buy genuine femara online, the publications must have appeared in a peerreviewed journal breast cancer 60 mile walk san diego purchase femara 2.5 mg free shipping, book chapter women's health center at the reading hospital buy femara with a visa, or government report (dissertations were not included) women's health center uga discount femara 2.5 mg with amex. The final criterion was that the evaluation must measure intervention effects using a pretest/posttest design or betweengroup differences design breast cancer 1 in 8 buy femara 2.5mg online. Additionally, evaluations of interventions designed to prevent dating violence, which commonly address partner violence more generally, were included if the intervention specifically included a component on sexual violence. A rigorous, unbiased search strategy is crucial because the validity of the review findings is directly related to the comprehensiveness of the search used to identify the relevant studies. This thoroughness is a key factor that distinguishes systematic reviews from traditional reviews (Khan et al. As mentioned above, two previously conducted literature searches were utilized to initially assess the body of literature on rape and dating violence prevention and to assist in the development of the inclusion criteria (Morrison et al. In addition, two literature searches were conducted utilizing electronic databases and a set of search 22 this document is a research report submitted to the U. Different search criteria were used to search different databases to best utilize the controlled vocabulary available from each of the databases. In general, the search terms used in the literature searches included keywords to describe the sexual offender, sexual offense, and victim; interventions and prevention programs; and evaluation and program effectiveness. To learn more about prevention efforts directed toward understudied populations, key search terms specific to three groups (special populations/individuals with disabilities, minorities, and adolescents) were included in the final search of electronic databases to ensure their inclusion. When an abstract did not provide 3 Because the unit of analysis for abstraction was the study rather than the article, multiple articles reporting on the same study were combined for abstraction. Articles that ultimately met the inclusion criteria were reviewed using the data abstraction method; those that did not were eliminated. In addition, the bibliographies of all included articles, as well as relevant review articles, were carefully examined as an additional measure to ensure that all articles meeting the inclusion criteria were located. Development of Data Abstraction and Quality Rating Forms Two standardized forms, a data abstraction form and a quality rating form, were used to review each article selected for inclusion. The data abstraction form was used to classify and organize information provided in each article. More specifically, data recorded on the form included descriptive information about the population and setting. Also on the form were sections in which the study measures, instruments, and results were recorded. The final section of the form included a place to indicate the quality score (tallied from the quality rating form; see below) and the major strengths and weaknesses of both the study. A corresponding key, with definitions of each of the elements to be included on the data abstraction form, was developed to ensure consistency in the information recorded on the form. Quality was assessed using a separate form specifically designed to evaluate the information entered on the data abstraction forms. For each article, three quality rating scores were given: one to assess the study description; one to assess the study design; and the total score, a sum of the study description and study design scores. Study description refers to the level of detail provided in the articles regarding study population, intervention characteristics, and outcome measures (4 items; 25 possible points). Study design refers to the research design used in the evaluation, sample size, duration of followup, retention rates, measures of program fidelity, and outcome variables (10 items; 70 possible points). The total quality score for a study was calculated by totaling the subscores and then dividing by the total number of possible points. For this review, the original upper limit (number of points) for the denominator was 95. Some articles, however, had a lower denominator because an item on the quality rating score did not apply. For example, the item relating to the intervention retention rate was not relevant to studies that evaluated an intervention that had only one session. A preliminary analysis of the quality rating scores resulted in the elimination of two questions (that addressed intervention retention rate and program fidelity) because a large number of the studies evaluated interventions that were only one session. The greatest number of points that a study could receive was therefore reduced to 85. In reporting the total quality score and the subscores for study design and description, percentages were used to provide a standard metric for comparison across studies. Team members completed two rounds of pilot testing in which they each abstracted data and rated the quality of the same article. Data Abstraction Process As noted above, the review system involved a threetiered data abstraction process that included a primary, secondary, and tertiary review of the article(s) for each study. The primary reviewer recorded all classifying information about the intervention and evaluation on the data abstraction form and completed a quality rating form. Following this review, the secondary reviewer reviewed the article(s) after which he or she examined the completed primary data abstraction form against the article(s), making modifications and noting discrepancies on the form, which was then saved as the Secondary Review 26 this document is a research report submitted to the U. Form (so as to retain the original data in addition to the modifications suggested by the secondary reviewer). Following completion of the quality rating form, the secondary reviewer compared his or her rating with that of the primary reviewer, thus ensuring an independent rating of quality for each article or set of articles. All discrepancies between the primary and secondary reviews were listed by the secondary reviewer on a separate Secondary Reviewer Discrepancies Form. The primary and secondary reviewers then met to discuss their independent reviews of the article(s). Resolutions and outstanding discrepancies were noted on the discrepancies form, and the secondary data abstraction form was further modified to reflect all decisions and modifications to the forms between the two reviews. The tertiary abstraction process included an independent review of the article(s) and quality assessment; a review of the primary and secondary data abstraction and quality forms and the decisions made between the two reviews; resolution of any discrepancies that had not been resolved. Each evidence table presents a concise summary of intervention characteristics, methodological details, and statistical results. The evidence tables were used to describe and summarize the entire pool of studies. Several key intervention and methodological characteristics were divided into meaningful categories, which allowed a tally of characteristics across articles. The characteristics and categories identified included the following: Study population characteristics target population (middle school, high school, college, and community) gender (males only, females only, both males and females) Study design characteristics baseline sample size study design (experimental, nonequivalent comparison group, randomized comparison group, and pre/posttest) postintervention followup period (less than 4 weeks, 1 to 3 months, 4 to 6 months, greater than 6 months) study retention rates at posttest and followup periods (less than 50 percent, 50 to 75 percent, greater than 75 percent) outcome measures (attitude, knowledge, behavior, victimization, and perpetration) Intervention characteristics format (curriculum components) delivery mode (format of presentation) duration (number of sessions and total number of contact minutes) Study quality quality score of low (less than 50 percent), medium (50 to 69 percent), or high (70 percent or greater) 28 this document is a research report submitted to the U. Studyspecific descriptions, as well as summary information about the pool of eligible studies on a variety of key study characteristics, are presented. Because the interventions and study designs of these articles differ from the studies of the general population, the results for these studies are presented separately. See appendix F for a discussion of the results of the synthesis of the studies on individuals with disabilities and appendix G the corresponding evidence tables. The standardized evidence table format includes (1) a detailed description of the study population and setting; (2) study design characteristics; (3) intervention characteristics; (4) outcomes measured; (5) a summary of the results; and (6) the quality scores. Summarizing population characteristics across the pool of studies proved challenging because many 29 this document is a research report submitted to the U. Seventy percent (n=35) of the programs targeted the college population, 16 percent (n=8) targeted high school, 8 percent (n=4) targeted middle school, and only 6 percent (n=4) targeted college and/or community populations. It is important to note that only one study meeting the criteria for this review was conducted outside of the United States, in southwestern Nigeria (article #80). The most common type of study design found was a nonequivalent comparison group (34 percent, n=17), followed by experimental (28 percent, n=14), randomized treatment comparison 30 this document is a research report submitted to the U. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U. Substantial variability in sample sizes at baseline was evident across the studies, with total sample sizes ranging from 7 to 1, 958 participants. Approximately 19 percent (n=8) of the studies had a sample of fewer than 100 subjects, and 26 percent (n=11) had baseline sample sizes greater than 500. In addition to a posttest, 38 percent (n=19) of the studies conducted a followup assessment. Approximately 40 percent (n=20) of the studies had followup periods of less than 1 month. Study retention rates (at both posttest and followup) ranged from 31 to 100 percent. At posttest, 17 (out of 27) studies had retention rates had retention rates greater than 75 percent; at followup, 7 (out of 19) studies had retention rates greater than 75 percent. Among the studies, the quality score totals ranged from 32 to 91 percent, with an average quality score of 60 percent. Approximately 28 percent (n=14) of the studies had quality score totals below 50 percent (low), as shown in exhibit 4. In addition to the total quality score, subscores for study description and study design were created and are presented at the study level in the evidence tables (see appendix E). The average study design quality subscore across the studies was 52 percent, and the average study description quality subscore was 80 percent. Because many of the instruments that were used to measure knowledge were also used to measure attitudes, these outcomes were combined into a singular outcome measure for this review. The outcome of victimization and perpetration assesses whether any sexual, physical, or psychological abuse was experienced or committed during or after the intervention. Dating behavior was measured through questions that assessed communication skills, conflict, violence, and other behaviors that are associated with acquaintance rape. Some of the studies included outcomes that assessed skills/ strategies gained as a result of the intervention. These included nonbehavioral assessments of assaultrelated cognitions and behavioral intentions. Other outcomes were found in the studies but either were not a direct measure of the intervention. Many of the studies (26 percent, n=13) included both behavioral and nonbehavioral outcome measures, whereas only 1 study assessed only behavioral outcomes. Approximately 86 percent (n=43) of the studies used knowledge and/or attitudes as an outcome measure, 24 percent (n=12) of the studies used victimization, 12 percent (n=6) used perpetration, 14 percent (n=7) measured dating behavior, and 20 percent (n=10) measured skills and/or strategies gained as a result of the intervention (see exhibit 4. The most commonly used instruments (or modified version of that instrument) include (1) Rape Myth Acceptance Scale, (2) Sexual Experiences Survey, (3) Adversarial Sexual Beliefs, and (4) Acceptance of Interpersonal Violence. Components of the curricula were included in the table if they were mentioned in at least five studies. Those that were mentioned with less frequency are listed as footnotes to the table. Similarly, the mode of presentation and target population were presented based on frequency within the studies. Numerous curriculum components (topics included in the intervention/program curricula) and presentation modes were found across the studies. Curriculum topics ranged from information on acquaintance/date rape to characteristics of offenders. The curriculum topics covered most frequently were (1) rape myths, (2) acquaintance/date rape information, (3) statistics on rape, and (4) prevention skills. The intervention presentation mode refers to the type of instruction and/or demonstration used in the program. As with curriculum topics, most interventions utilized more than one mode of presentation, the most popular being didactic presentations, discussions (including structured discussions), and videotapes. Other less commonly reported modes of presentation included workshops, theatrical presentations, and worksheets. Incentives for participation in the intervention were reported in 10 of the studies. The length of the programs ranged from 1 to 32 sessions, with an average of 4 sessions. Because the overall program duration varied markedly among the studies, intervention duration was operationalized as the total number of contact minutes. Some studies (n=10) did not report sufficient information to calculate contact minutes. The average number of contact minutes was 100; however, most interventions held sessions that lasted for 60 minutes. A metaanalysis yielding an estimate of the overall change in attitude, knowledge, or behavior is intuitively appealing, but the following substantial challenges precluded this approach: diversity and number of curriculum components included in the interventions variability in the mode of presentation and length of interventions variability in study design diversity of instruments and outcome measures used to assess intervention effects with inconsistency in the operationalization of the outcome measure and in the time frame in which the outcome is measured lack of data provided within the studies to create a common outcome measure variability in both the postintervention followup durations and retention rates within these followup periods variability in the analytic strategies used and the statistics reported. A categorical indicator of whether each study reported a positive, mixed, null, or negative intervention effect for the outcome measure was created. For reporting purposes, both the number and percentage of studies reporting positive, mixed, and null intervention effects are presented in the results table (see exhibits 4. Many studies determined the significance of the intervention effect using multiple strategies, at multiple followup periods, or among multiple intervention groupings or population subgroups. In this synthesis, studies were considered to have a positive intervention effect if all the results (at posttest and followup) of each outcome reported in the article were statistically significant in the desired direction. Studies were classified as having a mixed intervention effect if results across different outcomes. Studies were classified as having a null intervention effect if none of the results reported in the study were statistically significant. Studies were classified as having a negative intervention effect if all of the results reported in the article were statistically significant in an undesired direction. The division of the studies into these four categories was based on the results of the statistical tests reported in the evaluation. First, the diversity of the studies included in the review precludes the ability to provide conclusive evidence of effectiveness. Second, the current synthesis approach does not estimate the magnitude of the intervention effect. Third, dissertations were excluded from this review, resulting in a bias toward publications; studies reporting significant results are more likely to have been submitted and published. Finally, the synthesis strategy adopted in this study is likely to overestimate the number of studies that truly observed a significant intervention effect, partly because often only p values for significant findings are reported. Although subject to some degree of bias, this approach is advantageous because it allows for the inclusion of many studies (unlike more quantitative techniques such as metaanalysis, which typically result in the exclusion of many studies because of insufficient reporting or excessive heterogeneity among the pool of studies). Specifically, the results for the outcomes are broken down for the following categories: (1) type of outcome, (2) type of study design, (3) study retention rates, (4) followup period, and (5) quality score. It provides a snapshot of each of the studies and clearly shows the diversity of the interventions, study designs, and results. There were no meaningful patterns found across the 36 this document is a research report submitted to the U. However, it is important to note that three studies had null outcomes, and all three targeted femaleonly college (or college and community) populations. All of these studies used knowledge/attitude as the sole outcome and targeted the college and community populations. Eighty percent (n=40) of the studies were categorized as demonstrating mixed results, and 6 percent (n=3) reported a null intervention effect. As noted earlier, the results are further broken down into study subsets which are also presented in exhibit 4. Twentyfour percent (n=7) of the results for studies using only knowledge/attitude outcomes were positive, and none were null. Nine percent (n=1) of the results for the victimization outcome were positive; 33 percent (n=2) of the results for the perpetration outcome were positive; and 29 percent (n=2) of the results for the dating behavior outcome were positive. Seventynine percent (n=11) of the studies with an experimental design reported mixed results; none of these studies reported overall positive results. Ninetyone percent (n=10) of the studies using a randomized comparison group design reported mixed results, and 9 percent (n=1) reported positive results. Seventyfive percent (n=6) of the studies with a pretest/posttest design reported mixed results, and 25 percent (n=2) reported positive results. Fourteen percent (n=3) of the studies with 75 percent or greater study retention rates at posttest reported positive results; no studies with a followup retention rate of 75 percent or greater resulted in an overall positive intervention effect. Additionally, 21 percent (n=4) of studies with a followup period of less than 1 month had an overall positive intervention effect, and no studies with a followup period of greater than 4 months had an overall positive intervention effect. Fiftyseven percent (n=4) of studies reporting only positive intervention effects received low quality 37 this document is a research report submitted to the U. All of the studies (n=3) with null intervention effects received high quality scores. There were no studies with high quality scores that were categorized as having overall positive intervention effects. The following chapter provides further interpretation of the results, discusses limitations of this review, and identifies research gaps in the field. The audience for this report includes researchers, service providers, and policy makers. This chapter presents a summary of key findings, limitations of this evidencebased review, and areas for future research. The most common type of study design was a nonequivalent comparison group (34 percent), and 49 percent of the studies involved a followup assessment in addition to a posttest, with the majority of these studies (76 percent) conducting the followup within 3 months of the completed intervention. A variety of outcome measures were used, with the majority of the studies (58 percent) solely measuring changes in knowledge and/or attitudes. Twentysix percent of the studies included both behavioral and nonbehavioral outcomes. However, only 14 percent of the studies reported positive effects for all outcomes. Approximately 80 percent of the studies reported mixed intervention effects (both positive and null [or negative] results at posttest or followup across different outcomes or within the same outcome), and 6 percent reported solely null intervention effects.
Vitam inDand colorectaladenom a:R esults ofobservationalstudies A uth orY ear L ife O utcome F ollowup 25(O H)D N o women's health big book of exercises australia buy femara 2.5mg mastercard. The study included 71 percent nonHispanic white leading women's health issues generic 2.5 mg femara mastercard, 14 percent nonHispanic black menstrual cycle phases generic femara 2.5 mg with visa, 6 percent Mexican American menopause uterine cramps order femara online pills, and 9 percent from other races breast cancer awareness merchandise buy generic femara canada. The breast cancerspecific mortality was one of many cancerspecific mortality outcomes reported in this study women's health clinic midland tx cheap femara 2.5mg online. However menstrual cycle 7 days late purchase femara 2.5 mg with visa, in the second study breast cancer awareness purchase femara visa, when compared with the lowest quintile, quintiles 3 to 5 were associated with nonsignificantly elevated risks. In the one nested casecontrol study (methodological quality B) including both premenopausal and postmenopausal women, no relationship was found between vitamin D levels and risk of breast cancer. Vitam inDand breastcancer:R esults ofobservationalstudies A uth orY ear L ife Stage O utcome F ollowup VitD Concentration, N o. No qualified systematic reviews evaluated associations between serum vitamin D concentrations and the incidence of pancreatic cancer. The result was adjusted for age, month of blood drawn, years smoked, number of cigarettes smoked per day, reporting to have quit smoking more than three consecutive visits (>1 y) during the trial (19851993), occupational physical activity, education, and serum retinol. The study authors excluded islet cell carcinomas from analysis because the etiology for their pathogenesis might be different from that of exocrine tumors. The association was not significantly modified by season of blood collection (P for interaction > 0. Vitam inDand pancreaticcancer:R esults ofobservationalstudies A uth orY ear O utcome (no. We did not identify any eligible studies on the relationship of vitamin D with or without calcium and high blood pressure, preterm birth, or small infant for gestational age. Vitam inDand preeclam psia:R esults ofnested casecontrolstudies A uth orY ear L ife Stage O utcome F ollowup VitD Concentration, N o. D Earlyinpregnancy, approximately30 wk before outcome assessment 107 Vitamin D and Clinical Outcomes of Bone Health For bone health outcomes. Other factors may also contribute to the heterogeneity, such as diagnosis of fractures. In one cohort with a low percentage of vitamin D deficient participants, the association did not persist after adjustment for age and illness severity. In studies that reported an association, specific concentrations below which, declines in performance measures were increased, ranged from 50 to 87 nmol/L. There were no new data since the Ottawa report Pregnant & lactating women Not reviewed 111 Table 35. Ca (total study drug [17656420] polypharmacy carbonate 1200 taken/total study Mean 83 (7. In addition, it summarizes four observational studies on the association of vitamin D and allcause mortality. The above are applicable to older (5070 y) and elderly (fi71 y) men and women (mean age was >70 y in the included studies). As mentioned in the Methods section, we updated and reanalyzed published metaanalyses of mortality outcomes. One systematic review (Avenell 2008) examined only trials on fall prevention, and briefly described results on 84 83 mortality. Therefore, the Autier 2007 metaanalysis was used as the basis for our reanalysis. Comments See text in vitamin D and vitamin D + calcium sections for reanalyses of the separated trials. Study participants, vitamin D assays, and vitamin D status are not described in detail. We excluded 5 of 18 trials in the Autier 2007 metaanalysis: One trial was on patients with 85 86 congestive heart failure, one was published only in abstract form, in one trial the controls also 87 received supplementation with vitamin D, albeit with a smaller dose, and two trials used 88, 89 82 vitamin D injections. Overall, four trials (13, 899 patients) used only vitamin D supplementation without calcium. Overall, there were no significant effects of vitamin D supplementation on mortality. Melamed 2008 performed analyses in subgroups of men and women, and <65 or fi65 years of age, and found no significant associations (Table 33). Vitam inDand allcause m ortality:R esults ofcoh ortstudies A uth orY ear A ge O utcome F ollowup VitD Concentration, N o. The study was limited primarily by its inclusion of only a relatively small subset of participants and its reliance on selfreported hypertension without assessment of blood pressure measurements. Cases and controls (per the 2005 biennial questionnaire) were chosen from among those women without hypertension, cardiovascular disease, diabetes, obesity, or cancer at baseline (blood samples drawn from 1997 to 1999). No unique conclusions are possible for this life stage separate from those for people 51 to 70 years. The study participants also varied: either older men, older men and women, or men mostly in their 40s. In both study arms, systolic and diastolic blood pressures fell by equal amounts, resulting in no net difference between vitamin D supplemented and placebo groups. The German B quality trial of supplementation with combined vitamin D and calcium versus 97 calcium alone recruited older women (70 to 86 years) without severe hypertension. Systolic blood pressure decreased by 13 mm Hg in those supplemented with vitamin D and calcium compared with a 6 mm Hg decrease in those taking calcium alone (P=0. The study was limited by inadequate reporting of its study methods and lack of blinding. The men who received the vitamin D supplements had a net increase in systolic blood pressure of 4 mm Hg, which was close to statistically significant (P=0. The study of older women found a significant decrease in systolic blood pressure with relatively low dose 124 Findings by life stage. No significant effect on blood pressure was found of a single large dose of vitamin D. The trial of people with an average age of 70 years found no significant effect of a single large dose of vitamin D. Vitam inDand blood pressure:R esults ofR C Ts A uth orY ear A ge M ean Interventions, N o. Limitations in the study design and sources of bias highlight the need for additional research on vitamin D status in pregnancy and lactation, and the association with bone health outcomes. One systematic review and three primary studies evaluated supplemental intake of calcium and growth parameters in infants and children. Overall, the studies reviewed did not find a relationship between supplemental calcium intake and growth parameters. Two primary studies rated B in methodological quality and one primary study rated C provided additional information. There was no significant difference in height or weight gain among the groups at followup. No specific quantitative relationship between calcium intake and infant birth weight or length was 103 reported. Yes Unclear if all languages included; study quality assessed but not factored into the MA Table 47. C alcium and growth:R esults ofprim ary studies A uth orY ear M ean L ife Interventions, N o. N ospecificquantitative relationsh ipbetweencalcium intake andinfantbirth weigh tor [8201444] 6 mo length wasreported. No qualified systematic reviews evaluated the association between calcium intake and incidence of cardiovascular disease. In all studies, baseline calcium intake, assessed by food frequency questionnaires, were analyzed as predictors of longterm cardiovascular outcomes. We point out where there were "suggestions" of associations in cases where P values were about 0. Notably, the implied ranges of calcium intake within studied populations varied widely across studies. Median calcium intakes in the lowest and highest quintiles were 876 and 1916 mg/day, respectively; the overall median intake was 1379 mg/day. Cardiovascular death was analyzed in two large studies analyzed, separately in men and women. Neither found a significant association between calcium intake and cardiovascular death after 9 or 28 years in either men or women. Combined fatal and nonfatal cardiac events were analyzed in two large and one relatively small studies, in either both sexes together or just men. None found a significant association between calcium intake and cardiac events after 10 to 13 years. Cardiac death was analyzed in three large and one relatively small studies, separately in men and women. Overall, no consistent significant association between calcium intake and cardiac death after 8, 9, 12, or 28 years of followup was found in the various studies, in either men or women. No significant association was found with calcium intake after 12 years of followup. Total strokes were analyzed in five large and one relatively small studies, in both sexes combined, and separately for men and women. A Japanese and a Taiwanese study of men and women (4059 y and fi40 y, respectively) found progressively lower risks for stroke in people in higher quintiles of calcium intake after 13 and 11 years, respectively, in the setting of overall relatively low dietary calcium intake. A small Finnish study of both men and women (6599 y) found no significant association after 10 years. The two studies of men (40 to 75 years old) found suggestions of associations (not statistically significant), though with trends in opposite directions; one suggested the highest risk for stroke in men with calcium intake below approximately 750 mg/day after 8 years; one suggested the highest risk for cerebral infarctions in men with calcium intake above about 1000 mg/day after 14 years. The study of women (3257 y) found a nonsignificant trend after 14 years, but significantly higher stroke risk in those with calcium intake less than about 500 mg/day compared with women in the next two higher quintiles of calcium intake. None found a significant association between calcium intake and cardiac events after 10 to 13 years of followup. Two longitudinal cohort studies analyzed risk of cardiovascular death (death from cardiac or cerebrovascular events), separately in men and women, according to quintiles. Men within the calcium quintiles had mean calcium intakes that ranged from 250 to 665 mg/day. No significant association was found between calcium quintile and 105 cardiovascular death risk. In a study of Dutch civil servants (and spouses), 1340 men aged 40 to 65 years (regardless of cardiovascular history) were followed for 28 years. The calcium intake quintiles ranged from less than 585 mg/day to more than 1245 mg/day. No significant associations were found between calcium intake and risk of cardiovascular death; however, men in the lowest quintile (fi585 mg/day) had an adjusted odds ratio of cardiovascular death of 1. The Japanese study did not define cardiovascular mortality and the Dutch study did not report a complete analysis of the calcium intake quintiles. Women within the calcium quintiles had mean calcium intakes that ranged from 266 to 667 mg/day. No significant trend across quintiles or associations among quintiles was found for risk of cardiovascular death. However, women in the lowest quintile had about 25 to 30 percent lower risks of cardiovascular death than women in the next two higher quintiles. The calcium intake quintiles ranged from less than 445 mg/day to more than 850 mg/day. No significant associations were found between calcium intake and risk of cardiovascular death. Three longitudinal cohort studies analyzed combined fatal and nonfatal cardiac events, including coronary heart disease, acute myocardial infarction, and ischemic heart disease; two combined both sexes, one included only men. People within the calcium intake quintiles had median calcium intakes that ranged from 233 to 753 mg/day. No association was found between calcium intake 48 and risk of coronary heart disease events. In a small Finnish longitudinal study, 755 people aged 65 to 99 years, regardless of cardiovascular history were followed for 10 years; 17 percent had a cardiac event. No significant association was found between tertiles of calcium intake and all acute myocardial infarctions. This methodological quality C study did not report relevant data including information on the calcium intake within the tertiles. Men within the calcium quintiles had mean calcium intakes that ranged from 523 to 1377 mg/day. No significant association was found between calcium intake and risk of cardiac events. Four longitudinal cohort studies analyzed death from cardiac events, separately in men (3 studies) and women (3 studies). In the three studies of men, all found no significant association between calcium intake and cardiac death. In the Dutch civil servants study about 15 percent (ageadjusted) died of a cardiac event during 28 105 years of followup. In two studies, both described above, there was no significant association between calcium intake and cardiac death. In the Dutch civil servants study about 6 percent (ageadjusted) died of a cardiac event during 28 years of 105 followup. However, the study was of methodological quality B for this outcome because the outcome was not fully ascertained. The calcium intake quartiles ranged from less than 696 mg/day to more than 1425 mg/day. There was a suggestion of an association between lower calcium intake and higher risk of cardiac death, with a P value of 0. No significant association was found between calcium intake and nonfatal cardiac events. Six longitudinal cohort studies analyzed combined fatal and nonfatal strokes, in either both sexes combined, or men and women separately. The study found a significant association between baseline calcium intake and risk of stroke. The risk of stroke was progressively lower in progressively higher quintiles of calcium intake. Similar to the Japanese study, the typical calcium intake was relatively low by Western standards (the average dietary calcium intake was approximately 520 mg/day). Those in the lower two tertiles had about a 50 percent increased risk of ischemic stroke than those in the highest tertile (>591 mg/day). The third study of combined men and women, of older Finns (described above under Cardiac events, total), found no significant association with stroke among 755 people 48 followed for 10 years (stroke incidence 9. Both studies of men alone suggest trends across quintiles of calcium intake and stroke risk; however, the associations were in opposite directions. The study was of methodological quality C because there was large misclassification of stroke outcomes in a sample of subjects (521 percent). However, the trend of associations across quintiles was not statistically significant. One longitudinal cohort study (with subanalyses in men and women separately) and one nested casecontrol study (in men) evaluated fatal strokes. Both studies of men found no significant association between calcium intake and risk of stroke death. In a prospective cohort of about 18, 000 men aged 45 to 64 years, regardless of cardiovascular history, 245 died of stroke (1. The study also found no consistent association between calcium intake and stroke death. Among the outcomes for which studies had either statistically significant associations or suggestions of associations between calcium intake and cardiovascular events, the following findings of calcium intake level were reported. The association can be seen for quintiles 2 to 4, where women in the lowest quintile had a median calcium intake of 266 mg/day and those in the second quintile had a median calcium intake of 379 mg/day. Those in the second quintile had a median calcium intake of 344 mg/day and those in the lowest quintile 233 mg/day. The median calcium intakes in the first and second quintiles were 876 and 1178 mg/day, respectively. The median calcium intakes in the first and second quintiles were 395 and 645 mg/day, respectively. The majority of studies (and the large majority of individuals) included mostly people between the ages of about 40 and 70 years. Only a small 48 Finnish study (Marniemi 2005) restricted the study cohort to only older adults (65 years and older). This study found no significant associations between calcium intake and cardiovascular events. The findings that could be interpreted as an association between calcium intake and cardiovascular risk were mostly found in women (low calcium intake being associated with increased risk of cardiac death (in one of three studies) and stroke (in a single study), but with lowered risk of overall cardiovascular death (in one of two studies). The only potential associations between calcium intake and cardiovascular events in men were found for stroke; however, the two studies had opposite findings about the direction of the association. However, the one study of stroke in women was conducted in women who were mostly in this life stage. Overall, the majority of analyses found no significant association between calcium intake and most cardiovascular events. Only for stroke did at least two studies find significant associations between calcium intake and the outcome. For studies of people within this life stage, other significant associations were found in one of three studies of cardiac death in women (calcium intake below 696 mg/day was associated with increased risk) and in one of two studies of cardiovascular death in women (calcium intake above about 300 mg/day may be associated with increased risk).
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