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PubMed1997

[The relationship between primary and specialized care].

OBJECTIVES: To find the current situation regarding the relationship between Primary Care and specialist doctors. To find the defects in this relationship and to propose actions to improve the situation. DESIGN: Delphi technique. SETTING: Area Medical Directors, Medical Coordinators of Primary Care Centres, Hospital Medical Directors, Internal Medicine Service chiefs and Casualty directors from the entire Community of Valencia. RESULTS: After a qualitative analysis of the replies given in the first and second questionnaires, the 10 most serious problems for the Primary Care/Hospital relationship were extracted, along with 10 possible solutions to improve this relationship. CONCLUSIONS: The main problems detected between Hospital and Primary Care concerned the professional and organisational areas. The solutions suggested mainly centered on the organisational area. Specific differences were found in the prioritization of the replies, both for problems and solutions, depending on whether the point of view was Primary or Hospital Care.

Community Health Centers↗

PubMed1997

[Future developments in medicine: expert assessment].

In recent years studies forecasting the future such as Delphi expert surveys were carried out in various Western countries to make predictions on future developments in medicine and in the health care system. The answers draw a homogeneous picture: Cancer and dementia research as well as the development of materials for implantation and artificial organs are-in context of the demographic changes-of enormous relevance, whereas basic research receives less attention. Due to various technological developments in telecommunication and in diagnostics (sensors), sociomedical care at home is supported and will become more frequent.

Cross-Cultural Comparison↗

PubMedDate not supplied

[Improving the quality of reports on randomized controlled trials. Recommendations of the CONSORT Study Group].

This summary corresponds to the translation into Spanish of the Special Communication published in the Journal of the American Medical Association in August 1996, along with the editorial published in the same issue "How to report Randomized Controlled Trials. The Consort Statement". It describes the Consolidated Standards for Preparation of Controlled Clinical Trials, prepared by a work group made up of members of the SORT Group and of the Asilomar Work Group, along with the director of a magazine and the author of the report on a clinical trial. The work was carried out by means of a Delphi process and the result was a check list and a process diagram. The check list is made up of 21 items that mainly refer to methods, results and discussions on the report of a controlled clinical trial, identifying the necessary information in order to be able to evaluate the internal and external value of the report, judging the improvement to be positive for the patient, the editors and the reviewers of the magazines.

Delphi Technique↗

PubMedDate not supplied

[Validation in Spain of the dysfunctional ventilatory response to weaning].

In this article we present the study financed by the Sanitary Investigations Fund (FIS), with the objectives to prove that the Nursing Diagnosis of "Dysfunctional Ventilatory Response at Weaning" (DWRU) incorporated to the taxonomy of the North American Nursing Diagnosis Association (NANDA), is valid in Spain; as well as identify the items which configure its definition. A descriptive observational study was performed in nine Intensive Care Units belonging to six autonomous communities, including as study subjects 89 male and female nurses who are experts in yhe care of critically ill patients with mechanical ventilation. The model of validation proposed by Fehring and the Delphi Technique were used. The data were analysed calculating the average of the weights of each defining feature; percentage and average calculus; opinion percentages about the related factors; variability calculus; and factorial analysis of the result. The results make us conclude that Spanish nurses who have experience in taking care of critically ill patients, identify DWRU as a phenomenon which patients in our environment present and which can be treated by them. Besides, the identification of levels of DWRU into Severe, Moderate and Slight which the NANDA suggests, is better applied using an association of factors than defining higher and lower features.

Critical Care↗

PubMedDate not supplied

Providing family care in hospital.

Using the delphi technique, this study aimed to identify supportive nursing behaviours and some factors that inhibit the effective provision of family-centred palliative care in a hospital. Supportive nursing behaviours were identified and priority was given to the issues of symptom control, privacy, time and communication. Factors that hinder effective provision of family care focused mainly on the problems involved in balancing priorities, issues of disclosure and managing family conflict. The findings identified key areas of family-centred palliative care that warrant further investigation.

Delphi Technique↗

PubMed1997

[Health education on menopause: consensus on its contents].

OBJECTIVE: To define the standard knowledge women should have about the menopause in order to confront this stage successfully. DESIGN: Use of the Delphi technique to reach consensus with experts at a national level. PARTICIPANTS: 43 professionals were chosen from the biological, psychological and social health fields, who had professional experience in women's problems at this stage of their lives, and/or authors of books, articles, doctoral theses and other documents on the menopause. MEASUREMENTS AND MAIN RESULTS: Through three mailings, we obtained the views of 37 (86.04%) of the experts about the knowledge a woman should have of the menopause and the importance attached to each facet of this knowledge. Combining both criteria enabled us to classify the 266 Conceptual Elements (CE) that were expressed into three categories according to their relevance to women's knowledge. CONCLUSION: The Conceptual Framework on the Menopause is made up of a total of 173 CE, structured in 4 dimensions: biological aspects (23.12%), psychological and social aspects (24.8%), health risks (10.98%), and care, prevention and health promotion activities concerning the menopause (41.4%). This last dimension contained the highest percentage of specially relevant material (47.88% Level I CE).

Delphi Technique↗

PubMed1996

[Nursing diagnosis--questions which remained unanswered].

This article concerns one of the research questions in the project on 'Terminology in Dutch Nursing: Towards clarification, classification and standardization of nursing concepts', i.c. related to the conceptual definition of nursing diagnosis. On the one hand those parts are reported on which agreement was reached, by means of literature research and analysis of documents, interviews with key-informants and group discussions and through a Delphi research. On the other hand, those aspects of the proposed conceptual definition are elucidated on which discussions seem not to be closed yet or that are missing in the definition for lack of agreement. These discussion points are explored, thus following one of the recommendations of the research project on 'Terminology in Dutch Nursing', namely for further refinement of the proposed working definition of the concept nursing diagnosis. Finally some suggestions are made to realize this solicited refinement.

Delphi Technique↗

PubMed1998

Senior executive behaviors for the Army Dental Care System of the 21st century.

Challenges will most likely confront the Army Dental Care System as it moves into the next century. Like any other learning organization, the Army dental care system must develop a continuous stream of dynamic leaders to direct its evolution if it wants to survive. Using the Delphi method, the investigators surveyed senior dental leaders to determine the attitudes and behaviors believed to be required to perform successfully as commanders, residency directors, and senior staff officers. The essential executive behaviors appear to be consistent: be honest, act with integrity, be accountable for your actions, be dedicated to mission accomplishment, and perform your duty with care and compassion. Relying solely on ratings assigned to the behaviors, discriminant function analyses could predict proper group membership with an accuracy of 79.4%. When demographic information was included, prediction accuracy improved to 96.7%.

Adult↗

PubMed1998

The development of indications for the preoperative use of recombinant erythropoietin.

OBJECTIVE: To develop indications for the preoperative use of recombinant erythropoietin (rHuEPO) alone and in conjunction with preoperative autologous donation (PAD). DESIGN: A 2-round modified Delphi-consensus process. PARTICIPANTS: Nine physicians representing multiple clinical specialties, practice environments and geographic locations. METHOD: From evidence tables and a literature summary (MEDLINE database from January 1985 to August 1996) provided and using the RAND-UCLA appropriateness method, the physicians developed 264 indications for the preoperative use of rHuEPO by permuting 7 clinical factors (age, history of transfusion or antibody incompatibility, hemoglobin level, anemia of chronic disease, expected blood loss, presence of cardiovascular or cardiopulmonary disease and patient anxiety). These indications were rated on a 9-point appropriateness scale. Median scores and measures of agreement were determined. OUTCOME MEASURES: The significance of cost constraints or cost and blood supply constraints and the impact of each clinical factor on the ratings as judged by statistical analysis. RESULTS: Of the 264 indications, 54% were rated appropriate, 18% uncertain and 28% inappropriate. Expected blood loss had the greatest impact on the ratings (high expected blood loss had a 5.9 point more appropriate rating on the 9-point scale than low expected blood loss [p < 0.0001]). Preoperative hemoglobin level also significantly influenced the ratings (p < 0.0001). Compared with the clinical context, the ratings under the cost constraint were 1.0 less appropriate (p < 0.0001) for rHuEPO alone and 1.2 less appropriate for rHuEPO and PAD (p < 0.0001). The ratings for patients with moderate expected blood loss were significantly influenced by the cost constraint (less appropriate). CONCLUSIONS: Expected blood loss and preoperative hemoglobin level were the best indicators of rHuEPO appropriateness. Different contexts modify the appropriateness ratings of an expensive drug like rHuEPO.

Blood Loss, Surgical↗

PubMedDate not supplied

Nurse case managers' opinions of their role.

Delphi and focus group methods were used to identify nurse case managers' (NCMs') opinions regarding their professional role. This study convened 15 NCMs from a regional medical center in the southeastern United States. Findings present the highest-rated items influencing the NCM role, as well as a definition and model depicting the role's essential elements. In study questionnaires, participants were asked to identify and subsequently rate items in seven categories. The overall highest-rated item was the personal attribute of critical thinking and prioritizing. The second highest-rated response was the critical function of coordinating a multidisciplinary plan of care. Interdisciplinary support and participative decision making were consistently ranked as important organizational factors. In the category of impact on health care outcomes, identifying patient needs and services was highly rated. Participants suggested that NCM assignments should be based on clinical knowledge and expertise, with a focus on prevention. Practice implications, based on the findings, are emphasized.

Attitude of Health Personnel↗

PubMed2001

A new approach for measuring quality of care for women with hypertension.

BACKGROUND: Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. Existing systems have not always linked process measures to blood pressure outcomes. METHODS: A quality measurement system was developed and tested on hypertensive women in a West Coast health plan. An expert panel selected clinically detailed, evidence-explicit indicators using a modified Delphi method. Thirteen indicators (1 screening, 5 diagnostic, 5 treatment, and 2 follow-up indicators) were selected by this process. Trained nurses used a laptop-based tool to abstract data from medical records for the most recent 2 years of care. RESULTS: Of 15 004 eligible patients with hypertensive and other chronic disease codes, 613 patients were sampled, all eligible for the screening indicator. Of these, 234 women with an average blood pressure of 140/90 mm Hg or more, or a documented diagnosis of hypertension, were studied for the remaining indicators. The average woman received 64% of the recommended care. Most patients did not receive adequate initial history, physical examination, or laboratory tests. Only 37% of hypertensive women with persistent elevations to more than 160/90 mm Hg had changes in therapy or lifestyle recommended. The average adherence proportion to all indicators was lower in patients with uncontrolled blood pressure (>140/90 mm Hg) than in those with controlled blood pressure (54% vs 73%; P<.001). CONCLUSIONS: Quality of hypertensive care falls short of indicators based on randomized controlled trials and national guidelines. Poor performance in essential care processes is associated with poor blood pressure control.

Aged↗

PubMed2001

Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) presents a significant diagnostic and management challenge for primary care practitioners. Improving the accuracy and timeliness of diagnosis may result in improved quality and efficiency of care. OBJECTIVE: To systematically appraise the existing diagnostic criteria and combine the evidence with expert opinion to derive evidence- and consensus-based guidelines for a diagnostic approach to patients with suspected IBS. METHODS: We performed a systematic literature review (January 1966-April 2000) of computerized bibliographic databases. Articles meeting explicit inclusion criteria for diagnostic studies in IBS were subjected to critical appraisal, which formed the basis of guideline statements presented to an expert panel. To develop a diagnostic algorithm, an expert panel of specialists and primary care physicians was used to fill in gaps in the literature. Consensus was developed using a modified Delphi technique. RESULTS: The systematic literature review identified only 13 published studies regarding the effectiveness of competing diagnostic approaches for IBS, the accuracy of diagnostic tests, and the internal validity of current diagnostic symptom criteria. Few studies met accepted methodological criteria. While symptom criteria have been validated, the utility of endoscopic and other diagnostic interventions remains unknown. An analysis of the literature, combined with consensus from experienced clinicians, resulted in the development of a diagnostic algorithm relevant to primary care that emphasizes a symptom-based diagnostic approach, refers patients with alarm symptoms to subspecialists, and reserves radiographic, endoscopic, and other tests for referral cases. The resulting algorithm highlights the reliance on symptom criteria and comprises a primary module, 3 submodules based on the predominant symptom pattern (constipation, diarrhea, and pain) and severity level, and a subspecialist referral module. CONCLUSIONS: The dearth of available evidence highlights the need for more rigorous scientific validation to identify the most accurate methods of diagnosing IBS. Until such time, the diagnostic algorithm presented herein could inform decision making for a range of providers caring for primary care patients with abdominal discomfort or pain and altered bowel function suggestive of IBS.

Algorithms↗

PubMed1997

Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis. Canadian Stroke Consortium.

BACKGROUND: Despite several randomized controlled trials, the role of carotid endarterectomy for asymptomatic patients is controversial. Validated evidence-based guidelines are needed. METHODS: Thirty-five members of the Canadian Stroke Consortium, an independent body of cerebrovascular disease experts, reviewed evidence-based guidelines developed by the Canadian Task Force on the Periodic Health Examination. We held 3 rounds of Delphi consensus to solicit opinion and agreement. RESULTS: We found a high level of interrater agreement for all guidelines using multiple statistical measures. Members agreed that evidence is insufficient to endorse carotid endarterectomy for asymptomatic patients with angiographically proven stenosis of more than 60% (kappa = 0.70, P < .01). Reasons cited included concern over the reproducibility of low surgical morbidity rates in the community at large, the questionable clinical benefit conferred by surgery, and the lack of proven reduction in the risk of major disabling stroke. Screening the general population for asymptomatic stenosis was unanimously rejected. Also, screening even patients with risk factors or proven atherosclerosis at other sites was not endorsed (kappa = 0.91 and kappa = 0.79, respectively, both P < .01). CONCLUSIONS: There is insufficient evidence to recommend carotid endarterectomy for asymptomatic patients. Evidence is also insufficient to endorse a screening strategy even for patients with risk factors for carotid disease. While stroke prevention remains a critical goal, we do not recommend that it be accomplished by screening or by performing carotid surgery in asymptomatic patients.

Canada↗

PubMed1998

A comparison of the opinions of experts and readers as to what topics a general medical journal (JAMA) should address.

CONTEXT: Journal editors are responsible to many publics, and their choices of articles to publish are a frequent source of dispute. OBJECTIVE: To assess the extent of agreement between topics identified by experts and by JAMA readers as most important for publication. DESIGN AND PARTICIPANTS: Modified Delphi process of polling of JAMA Editorial Board members and senior staff (ie, experts) in 1996, and masked direct mail survey of a stratified sample of JAMA readers in late 1996 and early 1997. MAIN OUTCOME MEASURES: Agreement between experts and readers on the topics most important for JAMA to deal with in 1997. RESULTS: Of 55 experts polled, the 40 respondents (73% response rate) proposed 178 topics. Editing to combine similar topics left 73. The same 55 persons were asked to stratify all 73 alphabetically arranged topics on a scale of 1 to 5 (85% [47/55] response rate). They were then given the results of this ballot and asked to vote again (76% [42/55] response rate). Of the 55 experts, 40 attending the annual editorial board meeting were given all results; 39 attendees voted on the final topics. In response to the mail survey, a single pass of the same 73 topics yielded a response rate of 41.6% (208 returns). Nonresponders were roughly equivalent to responders demographically. Readers agreed with the experts on only 3 of the top 10 subjects: managed care, cancer, and aging. CONCLUSION: Expert opinion and the opinion of readers as to what JAMA should emphasize vary widely.

Data Collection↗

PubMed2025

Clinical Actionability of Genetic Findings in Cerebral Palsy: A Systematic Review and Meta-Analysis.

IMPORTANCE: Single gene variants can cause cerebral palsy (CP) phenotypes, yet the impact of genetic diagnosis on CP clinical management has not been systematically evaluated. OBJECTIVE: To evaluate how frequently genetic testing results would prompt changes in care for individuals with CP and the clinical utility of precision medicine therapies. DATA SOURCES: Published pathogenic or likely pathogenic variants in OMIM genes identified with exome sequencing in clinical (n = 1345) or research (n = 496) cohorts of CP were analyzed. A systematic literature review for evidence of effective therapies for specific genetic etiologies was performed. STUDY SELECTION: Nonstandard interventions that led to a detectable improvement in a defined outcome in individuals with variants in the gene of interest were included. DATA EXTRACTION AND SYNTHESIS: Literature was evaluated using PRISMA guidelines. A diverse, expert working group was established, scoring rubrics adapted, and scoring consensus built with a modified Delphi approach. MAIN OUTCOMES AND MEASURES: Overall clinical utility was calculated from metrics assessing outcome severity if left untreated, safety and practicality of the intervention, and anticipated intervention efficacy on a scale from 0 to 3. RESULTS: Of 1841 patients with CP who underwent exome sequencing, 502 (27%) had pathogenic or likely pathogenic variants related to their phenotype. A total of 243 different genes were identified. In 1841 patients with identified genetic etiologies of CP, 140 (8%) had a genetic etiology classified as actionable, defined as prompting a change in clinical management. Also identified were 58 of 243 genes with pathogenic or likely pathogenic variants with actionable treatment options: 16 targeting the primary disease mechanism, 16 with specific prevention strategies, and 26 with specific symptom management. The level of evidence was also graded according to ClinGen criteria; 45 of 101 interventions (44.6%) had evidence class D or below. The potential interventions have clinical utility with 98 of 101 outcomes (97%) being moderate-high severity if left untreated and 63 of 101 interventions (62%) predicted to be of moderate-high efficacy. Most interventions (72 of 101 [71%]) were considered moderate-high safety and practicality. CONCLUSIONS AND RELEVANCE: The findings indicate that actionable genetic findings occurred in 8% of individuals referred for genetic testing with CP. Evaluation of potential efficacy, outcome severity, and intervention safety and practicality indicates moderate-high clinical utility of these genetic findings. Genetic sequencing can identify precision medicine interventions that provide clinical benefit to individuals with CP. The relatively limited evidence base underscores the need for additional research.

Humans↗

PubMed2000

Balneotherapy for rheumatoid arthritis and osteoarthritis.

BACKGROUND: Balneotherapy (hydrotherapy or spa therapy) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain and as a consequence to relieve patients' suffering and make them feel well. OBJECTIVES: To perform a systematic review to assess the effects of balneotherapy for rheumatoid arthritis and osteoarthritis. SEARCH STRATEGY: Using the Cochrane search strategy, studies were found by screening: 1) The Medline CD-ROM database from 1966 to June 1999 and 2) the database from the Cochrane Field 'Rehabilitation and Related Therapies', which contains also studies published in journals not covered by Medline. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. To perform an adequate assessment of the methodological quality the languages of the publications had to be: Dutch, English, French or German. Date of the most recent literature search: June, 1999 SELECTION CRITERIA: Studies were eligible if they were randomized controlled trials (RCT) comparing balneotherapy with any intervention or with no intervention. Patients included had rheumatoid arthritis (RA), osteoarthritis (OA) or some other form of arthritis. Trials incorporating patients with definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) (Ropes 1958) (these criteria have changed over time) or by the criteria of Steinbrocker (1949) were regarded as a separate group. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be the main outcome measures. DATA COLLECTION AND ANALYSIS: A criteria list used to assess the methodological quality was the one developed at the Department of Epidemiology at the Maastricht University, called "the Maastricht list". The quality scores and data abstraction of the studies were carried out independently by two reviewers (HdV, RdB). Disagreements were solved by consensus. MAIN RESULTS: Ten trials with 607 patients were included in this review. Most trials reported positive findings, but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. Just one of the randomized trials mentioned an intention-to-treat analysis and only three performed a comparison of effects between groups. Pooling of the data was not performed, because of heterogeneity of the studies, multiple outcome measurements, and, apart from two studies, the overall data presentation was too scarce to enable pooling of the data. REVIEWER'S CONCLUSIONS: One cannot ignore the positive findings reported in most trials. However the scientific evidence is weak because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, quality of life), Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the efficacy of balneotherapy cannot be provided at this time. Flaws found in the reviewed studies could be avoided in future trials.

Arthritis, Rheumatoid↗

PubMed2001

Speech and language therapy for dysarthria in Parkinson's disease.

BACKGROUND: Dysarthria is a common manifestation of Parkinson's disease which increases in frequency and intensity with the progress of the disease (Streifler 1984). Up to 20% of Parkinsonian patients are referred for speech and language therapy (S & L T), its aim being to improve the intelligibility of the patient's speech. OBJECTIVES: To compare the efficacy of speech and language therapy versus placebo or no interventions in patients with Parkinson's disease. SEARCH STRATEGY: Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, ISI-SCI, AMED, MANTIS, REHABDATA, REHADAT, GEROLIT, Pascal, LILACS, MedCarib, JICST-EPlus, AIM, IMEMR, SIGLE, ISI-ISTP, DISSABS, Conference Papers Index, Aslib Index to Theses, the Cochrane Controlled Trials Register, the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR; and examination of the reference lists of identified studies and other reviews. SELECTION CRITERIA: Only randomised controlled trials (RCT) were included. DATA COLLECTION AND ANALYSIS: Data were abstracted independently by KD and RW and differences settled by discussion. MAIN RESULTS: Three randomised controlled trials were found comparing speech and language therapy with placebo for speech disorders in Parkinson's disease. A total of 63 patients were examined. The loudness of the patients' voices were increased by between 7-18%, depending on the speaking task being performed. It is likely that this is a clinically significant improvement. After six months the degree of improvement was reduced but was still statistically significant. Overall measures of dysarthria were measured in two trials and also improved. The clinical significance of these improvements was less clear cut as intelligibility of speech was not measured in any of these studies. REVIEWER'S CONCLUSIONS: Considering the small number of patients examined, the methodological flaws in many of the studies, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of speech and language therapy for dysarthria in Parkinson's disease. A Delphi-style survey is needed to develop a consensus as to what is 'standard' S< for dysarthria in Parkinson's disease. Then a large well designed placebo-controlled RCT is needed to demonstrate speech and language therapy's effectiveness for dysarthria in Parkinson's disease. The trial should conform to CONSORT guidelines. Outcome measures with particular relevance to patients should be chosen and the patients followed for at least 6 months to determine the duration of any improvement.

Dysarthria↗

PubMed2004

Propranolol for migraine prophylaxis.

BACKGROUND: Propranolol is one of the most commonly prescribed drugs for migraine prophylaxis. OBJECTIVES: We aimed to determine whether there is evidence that propranolol is more effective than placebo and as effective as other drugs for the interval (prophylactic) treatment of patients with migraine. SEARCH STRATEGY: Potentially eligible studies were identified by searching MEDLINE/PubMed (1966 to May 2003) and the Cochrane Central Register of Controlled Trials (Issue 2, 2003), and by screening bibliographies of reviews and identified articles. SELECTION CRITERIA: We included randomised and quasi-randomised clinical trials of at least 4 weeks duration comparing clinical effects of propranolol with placebo or another drug in adult migraine sufferers. DATA COLLECTION AND ANALYSIS: Two reviewers extracted information on patients, methods, interventions, outcomes measured, and results using a pre-tested form. Study quality was assessed using two checklists (Jadad scale and Delphi list). Due to the heterogeneity of outcome measures and insufficient reporting of the data, only selective quantitative meta-analyses were performed. As far as possible, effect size estimates were calculated for single trials. In addition, results were summarised descriptively and by a vote count among the reviewers. MAIN RESULTS: A total of 58 trials with 5072 participants met the inclusion criteria. The 58 selected trials included 26 comparisons with placebo and 47 comparisons with other drugs. The methodological quality of the majority of trials was unsatisfactory. The principal shortcomings were high dropout rates and insufficient reporting and handling of this problem in the analysis. Overall, the 26 placebo-controlled trials showed clear short-term effects of propranolol over placebo. Due to the lack of studies with long-term follow up, it is unclear whether these effects are stable after stopping propranolol. The 47 comparisons with calcium antagonists, other beta-blockers, and a variety of other drugs did not yield any clear-cut differences. Sample size was, however, insufficient in most trials to establish equivalence. REVIEWERS' CONCLUSIONS: Although many trials have relevant methodological shortcomings, there is clear evidence that propranolol is more effective than placebo in the short-term interval treatment of migraine. Evidence on long-term effects is lacking. Propranolol seems to be as effective and safe as a variety of other drugs used for migraine prophylaxis.

Adrenergic beta-Antagonists↗