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Munchausen by internet: current research and future directions purchase paxil 30 mg without a prescription. Pneumographic and medical investigation of infants suffering apparent life threatening episodes order cheap paxil on-line. Journal of Paediatrics and Child Health 1991; 27:349-353 order paxil discount. The deceit continues an updated literature review of Munchausen syndrome by proxy. Last modified: November, 2017 12 Tooby J, Cosmides L. Proceedings of the British Academy 1996; 88:119-143. Malingering, hysteria, and the factitious disorders. An evaluation of malingering screens with competency to stand trial patients: a known-groups comparison. Law and Human Behaviour 2006; Oct 21 [Epub ahead of print]. The Forum was the public space in ancient Rome where judicial and other public business was debated and decided. Forensic psychiatry is that part of psychiatry which deals with patients and problems at the interface of the legal and psychiatric systems (Gunn, 2004). It is reasonable for students to learn some basic principles, as most doctors will be involved, at least peripherally, on occasions. While the main work of forensic psychiatrists is assessing individuals and presenting evidence in court (which is the focus of this chapter), they are also involved in the care of people incarcerated in forensic psychiatry hospitals (which may be located inside or outside prison walls). Recently, the role of the forensic psychiatrist has widened. They are now being asked to advise on, and sometimes manage, difficult and dangerous patients in civil situations who have not committed offences. There is frequently public outcry when a criminal act has been performed and the defence raises issues of mental health. There is a feeling that something unfair is happening, a bad person is cheating or tricking the legal system, a guilty person is avoiding punishment (as with the Hinckley and McNaughton cases, on pages 2 & 3). Joseph Fritzl was accused [and found guilty] of imprisoning and raping his daughter over decades, and of contributing to the death of a grandchild. This newspaper clipping exemplifies an all too common tendency to premature judgement and ignorance of the appropriate legal processes. When John Hinckley shot President Reagan (1981) and was found not guilty by reason of insanity (NGI), the public was outraged. This resulted in a new and tougher law governing the insanity defence in the USA: the Comprehensive Crime Control act of 1984. The law and psychiatry are different disciplines; they serve different purposes and are based on different concepts. Also, the law deals with concepts in a dichotomous fashion, such as, guilty/not guilty, and sane/insane, while psychiatry (and medicine) operate in a shades of grey fashion, where options about diagnosis, treatment and prognosis are continuously kept open and opinion changes with new developments in the case over time. Naturally, the interface between psychiatry and the law (which comes under the spotlight when an offence has been committed and the accused person appears to be suffering a mental disorder) is challenging. A complication is that forensic psychiatrists must frequently balance complex ethical issues. For example, this expert may need to balance conflicting responsibilities – such as, if the he/she learns that a patient represents a danger to another civilian. Not only do the interests of the patient (prisoner) need to be protected, but also those of the wider community - and these may be incompatible (Candilis and Huttenbach 2015). We are simply touching on principles - laws differ from one jurisdiction to another, and in any location, there may be overlapping laws. Fitness to plead Most would agree, it would be unfair to try (and potentially punish) people who were unable (through mental incapacity) to participate in their own legal defence. Opinions are sought from psychiatrists on fitness to plead (also called competency), but the final decision is made by the court. While the legal process is complicated, the psychiatric aspects of fitness to plead are straightforward. The important issue is not guilt or innocence, or the nature or severity of any disorder, but the ability of the individual to function in court. The universal features are that the defendant must have the ability, 1) to understand the charge and possible penalties, 2) to understand the court proceedings, and 3) to give instructions to a defence lawyer. When an individual is unfit to plead, the crime is rarely serious. Such people are highly disorganized and therefore incapable of executing complicated, devious, secret plans. Most often, when the person is unfit to plead, the offences are damage to property or minor assault. If the defendant is unfit to plead because of a treatable condition, such as schizophrenia, he/she is kept in custody and offered treatment. If and when the ability to plead is gained, the case is heard. This means the patient spends months in a prison hospital before a verdict is reached. Thus, the time spent in custody is usually significantly lengthened by the inability to plead. Some people who are charged do not regain the ability to plead. Such people may remain in prison or some form of mental health facility indefinitely. In the case of minor offences, the patient may eventually be rehabilitated into the community and the charges are dropped. Criminal responsibility For a person to be found guilty, two basic elements must be satisfied.

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FINDINGS FROM THE CASE STUDIES was then to be handed over to the alliance members purchase paxil 30mg with mastercard. The main function of the theorising on the part of the GP clinical chairperson can therefore be seen as holding out a vision of how services could work together differently proven 10mg paxil, without specifying detailed mechanisms for how to achieve this: the provider organisations in the alliance should take responsibility for meeting the adaptive challenge cheap 20 mg paxil fast delivery. The strategic commissioning arena relevant to this initiative was that of the CCG governing body. The mental health clinical lead was also a member of this board and obtained backing from this board. In terms of institutional work, clinical leadership in this arena can be seen as involving advocacy and achieving the vesting of resources and responsibilities in alliance working. Clinical leadership and institutional work also took place in the operational delivery arenas as senior provider clinicians shaped the actual practices of working in alliance mode. But the model of separate organisations all coming under one host organisation and being subsumed, I am not for. Clinical psychologist An underlying tension derived from the different professional ethos of providers that are closer to the medical model associated with psychiatry as opposed to clinical psychology or family therapy which work with a more socially based therapeutic approach. Staff in each provider preferred to continue to manage the professional tensions and syntheses they already knew, rather than be cast into more direct interaction with clinical and managerial traditions they knew less well. This was a form of institutional work: developing the interfaces between the patterns of service activities offered by each alliance member. This institutional work involved the development of a normative network of clinicians across each alliance. We have already described how clinicians cohered around the shared articulation of providing a more integrated experience for service users. Rather than seeking to define new ways of treating mental illness, these clinicians were involved in advocating and developing new ways of blending or combining existing definitions. And I really think this is one of the problems with the whole PbR [payment by results] system is that somebody could drop down to the wrong cluster, and then you begin to get worried about how long you can continue to see them for. Senior clinical psychologist 44 NIHR Journals Library www. Alliance members said that they needed to articulate the need for the most effective intervention models for the clientele being seen, for example making the case for models that go beyond the six-session brief therapy model as the standard, given the complexity and severity of many cases. There was also evidence of productive tension between the clinical leadership perspectives of commissioners and providers. Although both groups embraced the overall goals of providing seamless and comprehensive services for users, commissioners tended to emphasise the collective responsibility of providers to fill gaps by working creatively with existing resources, whereas providers emphasised the responsibilities of commissioners to fill specifically identified gaps. A feature of clinical leadership on both sides was the willingness to work through such tensions. Case A2: innovating in urgent care – a combined general practitioner and paramedic service Across the country as a whole, urgent and emergency care has been a recognised problem across the health service for some time. There has been rising demand and the service has found it difficult to cope with the numbers and the expense. A consistent case has been made for the need to reduce the numbers attending A&E departments. Many different ideas have been put forward about how to resolve the problem. In this case study we focus on one specific innovation which seeks to tackle the issue. It is a study of leadership from the CCG in the redesign of one focused aspect of urgent care. It involved stakeholders from the ambulance service as well as local GPs. Leadership at the initiation stage This urgent care initiative emerged from discussions at the CCG urgent care programme board. This was chaired by a GP, from the CCG governing body, and its deputy chairperson was the clinical lead consultant in emergency medicine from the acute hospital. The board included a range of other clinicians: a senior nurse from the acute hospital emergency department; senior paramedics from the regional ambulance trust; and senior GPs from an urgent primary care centre co-located with the acute hospital emergency department and from the out-of-hours GP provider. Its membership also included a patient representative and managers from the CCG and from the various providers involved in urgent and emergency care. This in effect meant that selected 999 calls were allocated to primary care. The idea emerged from the urgent care programme board. Further theorising work for this initiative was undertaken by a senior paramedic (employed by the ambulance service), in conjunction with the clinical lead from the emergency department of the local hospital. They were aware that paramedics often felt frustrated in their attempts to keep patients from being conveyed to hospital because they could not find a way to refer effectively to any local services which could provide care to patients at home. Shortly after the production of an initial scoping document, the ambulance trust manager invited the GP chairperson of the urgent care board to go on an ambulance shift to see the kinds of cases that ambulances are called to and to assess for herself how a GP within an ambulance crew could intervene to treat patients at home and avoid the need to carry them to A&E. That GP-led alternative service was at the heart of the idea. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 45 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE CASE STUDIES The main target group from the outset was elderly people with complex conditions and multiple medications. Ambulance crews often did not feel confident that they could leave such patients at home, and so they tended to play safe and transfer such cases to A&E. However, with a GP as a member of a paramedic crew, it was judged that they would have the professional knowledge and skills to make an informed assessment and to allow some immediate treatment decisions to be made. These GP crew members would also be able to directly refer patients rapidly to other services that could provide care at home. These wider services included a multidisciplinary, first-response duty team, specialist teams for respiratory conditions and heart failure and out-of-hours community nurses who can deal with dressings and catheter problems. Such services meant that many patients can receive the same treatment at home as they would in hospital, without having all their home-based care plans cancelled and their independence undermined. Paramedics are typically less familiar with the well-developed range of home-oriented care services in the borough, and in any case may not have the experience to refer patients to them in the same rapid manner as a GP. The wider context of establishing the pilot is that, across London, ambulance crews were perceived as commonly experiencing difficulty in getting support from primary care when they encountered a patient whom they judged could be cared for outside of hospital. They sometimes conveyed patients to hospital in the full knowledge that it would be better not to.

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How an insomniac reacts to his or her sleep disruption Maintenance of respiration during sleep is dependent on may also predict his or her experience of daytime function­ intact central nervous system centers controlling respiration purchase generic paxil on-line, ing cheap paxil 20 mg visa. Several hypotheses related to this notion are offered best paxil 10mg. The emphasis of clinical and re- about it during the day (20,25). Insomniacs simply may search approaches to sleep-disordered breathing has focused need more sleep than they are getting or be hypersensitive on this last point—loss of airway patency. Two classes make to small amounts of sleep loss (17). Consistent with these up most of the obstructive sleep apnea patients. A smaller proportion of patients are of normal objective sleep disturbances, respectively. Like other studies, weight, but are also prone to closure of the upper respiratory differences in performance, alertness, and night sleep pa­ tract. These latter individuals typically have oral or maxillo­ rameters were not evidenced. These data suggest that the complaints of hol, or other sedating drugs increases the propensity for insomniacs may be differentiated and better understood by apneic events. Thus, as apneics undergo chronic sleep loss way of personality subtypes. The inconsistency may well derive from the heteroge­ havioral performance—repeated arousals from sleep or sleep neous samples form the different studies. Not aged adults and is characterized by respiratory pauses owing only do patients feel drowsy, but also they rapidly switch to upper airway closure during sleep, which result in acute from waking to sleeping or cataplectic states—the sudden hypoxemic events and transient arousals from sleep. Consequences of sleepiness and fatigue can neurobehavioral performance. Decrements in performance, lead to a myriad of neurobehavioral performance decre­ including vigilance, and attentional and complex cognitive ments and potentially dangerous situations, such as traffic functioning problems, may be direct consequences of sleepi­ and work accidents. In the Findley and associates study, persons with mary public health concerns and the populations that are narcolepsy demonstrated marked impairments as the dura­ most vulnerable to the consequences of sleepiness and fa­ tion of the task increased, with shorter latencies on the tigue, such as travelers, truck drivers, and shift workers. In addition, addition, neurobehavioral consequences of experimentally 20% to 30% of narcoleptics have comorbid major depres­ induced sleep loss are reviewed. Traffic Accidents Until recently, altered cholinergic and monoaminergic systems have been implicated in the pathophysiology of this According to the National Highway Traffic Safety Adminis­ disorder (40); however, new work from canine strains with tration, 56,000 automobile accidents per year are caused by narcolepsy, and a strain of Orexin knockout mice (manifest­ drivers falling asleep at the wheel (44). Accidents involving ing a phenotype highly similar to narcolepsy) reveals that truck drivers result in approximately 4,800 fatalities per year a genetic defect, disruption of a hypocretin (Orexin) gene (45) and fatigue is the most common cause (46). Sleep- may be the primary cause of narcolepsy (41,42). Orexins related automobile accidents are associated with fatalities are a class of hypothalamically derived peptides with known (1. Drowsiness can lead to rapid and frequent cently they were not recognized as sleep-modulating neuro­ uncontrolled sleep or microsleeps, frequent prolonged eye- transmitters. The homeostatic need for sleep and to partial, temporary relief of the sensations. Daytime performance impair­ day—that can have severe personal and public health conse­ ments that appear secondary to the sleep disruption have quences. Sleepiness is reported by 70% of shift workers (52). Shift workers have a higher incidence The evaluation of sleepiness is critical not only to minimize of traffic accidents as a result of sleepiness while commuting, impairment in social or occupational settings, but also to compared to non-shift working individuals (56). Shift Chapter 130: Sleep Loss and Sleepiness 1899 workers are also at an increased risk for injury and accidents Sleep Deprivation: Experimentally (51). Three Mile Island, Exxon Valdez, and the Space Shut­ Induced tle Challenger represent disasters where fatigue among Sleep loss results in compromised neurobehavioral perfor­ nighttime workers has been implicated. Various per­ Both intrinsic biological and environmental factors con­ formance assessments probe the functional capability of the tribute to the problem sleepiness of shift workers. Shift workers exist measures of sleepiness and neurobehavioral problems. Psy­ in states of chronic sleep debt because of insufficient sleep chomotor vigilance and probed memory impairment as well during each 24-hour period. Human entrainment to the as somatic complaints appear to increase during acute total natural 24-hour light/dark cycle establishes a fixed neuro­ and repeated partial sleep deprivation (62–65). Some stud­ biologic propensity to be active, alert, and performing dur­ ies have been unable to show cognitive impairment during ing the daylight hours, and to sleep during the nocturne sleep deprivation (66), leading to speculation that chronic (58). Shift work requires maximum psychomotor and cog­ partial sleep deprivation does not result in cumulative de- nitive performance at night, that time when virtually all creases in performance (67,68). A number of factors may zeitgebers are cueing the endogenous circadian pacemaker have contributed to the disparate outcomes among studies to reduce arousal, activity, and sleep. Thus, not only must of waking performance after chronic sleep restriction. Many shift workers compensate for societal disruptions to their of the negative studies were limited by the fact that the sleep, such as noise and pressures to socialize and perform primary outcome measures were performance assessments domestic chores, but they must also overcome daylight and with robust practice effects (62). Learning curves confound darkness time cues to work and sleep, respectively (53). In other words, repeated testing on a Jet Lag measure with a learning curve will lead to improved perfor­ Jet lag is a condition following transmeridian travel that mance scores. Thus, if cumulative sleep loss does impair involves a myriad of problems. Symptoms include daytime performance on this measure, the decrement will be masked sleepiness and fatigue, impaired daytime cognitive perfor­ by the learning-derived improvement. Performance vigi­ dark cycle increases with the number of time zones crossed. Stud­ lag are mediated by disruptions of the sleep and circadian ies utilizing such measures show increased lapses and height­ systems. Both the homeostatic mechanism for sleep (sleep ened variability of performance during sustained vigilance drive that increases as duration of wakefulness increases) tasks (62), all of which show deterioration after acute, total and circadian neurobiology interact to determine neurobe­ sleep deprivation, and after chronic partial sleep depriva­ havioral alertness and performance (59). Reduction in speed of response, although not a hour light/dark cycle, although sleep loss incurred by travel function of lapses or failure to respond, appear attributable can also serve to exacerbate the condition. The endogenous to a decline in the ability to continuously allocate attention circadian pacemaker does not immediately adapt to the new to the task and to respond motorically as rapidly as possible.

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Summary of strength of evidence and effect estimate for KQ 3—one rate-control procedure versus another Outcome Strength of Evidence and Effect Estimate Ventricular Rate Control SOE=Low (1 study cheap paxil 20 mg on-line, 40 patients) No difference between those assigned to anterior vs generic paxil 30 mg overnight delivery. Antiarrhythmic Drugs and Electrical Cardioversion for Conversion to Sinus Rhythm Our review identified 42 studies exploring the use of antiarrhythmic drugs and electrical cardioversion for conversion to sinus rhythm purchase paxil amex. Table 27 summarizes the strength of evidence for the available comparisons and evaluated outcomes. Details about the specific components of 111 these ratings (risk of bias, consistency, directness, and precision) are available in the Results chapter. Across outcomes and comparisons, although the included evidence was from RCTs with an overall low risk of bias and the evidence was based on direct outcomes, some findings were limited in terms of precision and consistency, as well as by the available number of studies. Summary of strength of evidence and effect estimate for KQ 4 Restoration of Sinus Maintenance of Sinus Recurrence of AF Treatment Comparison Rhythm Rhythm Various Methods for SOE=High (4 studies, 411 SOE=Insufficient (1 study, SOE=Low (1 study, 216 External Electrical patients) 83 patients) patients) Cardioversion (Biphasic OR 4. No No significant benefit for Significant benefit for Significant benefit of Drug Enhancement) patients given ibutilide or patients given verapamil verapamil pretreatment metoprolol pretreatment or metoprolol (p=0. Rhythm-Control Procedures and Drugs for Maintenance of Sinus Rhythm Our review identified 65 RCTs evaluating procedures for rhythm control and 18 studies evaluating the safety or effectiveness of pharmacological agents with or without external electrical cardioversion for maintaining sinus rhythm in patients with AF. Tables 28 and 29 summarize the strength of evidence for the evaluated therapies and outcomes. Details about the specific components of these ratings (risk of bias, consistency, directness, and precision) are available in the Results chapter. Across outcomes and comparisons, although the included evidence was from RCTs with an overall low risk of bias and used direct evidence, the findings were often inconsistent or imprecise, limiting our findings. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies Treatment Restoration of Maintenance Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm of Sinus AF CV Mortality Hospitaliza- Symptoms/ Mixed Events Rhythm tions Control of AF Embolic Symptoms Events Including Stroke) Transcatheter SOE= SOE=High (8 SOE= All-Cause: CV: SOE= SOE= SOE= Stroke: SOE= SOE= PVI vs. AADs Insufficient (No studies, 921 Insufficient (No SOE= Moderate (2 Insufficient (No Insufficient Insufficient (No Insufficient studies) patients) studies) Insufficient (1 studies, 268 studies) (6 studies, 647 studies) (1 study, 67 OR 6. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm of Sinus AF CV Mortality Hospitaliza- Symptoms/ Mixed Events Rhythm tions Control of AF Embolic Symptoms Events Including Stroke) Transcatheter SOE= SOE=Low (5 SOE= All-Cause: SOE= SOE= SOE= SOE= SOE= Circumferential Insufficient (1 studies, 500 Insufficient (No SOE=Low (1 Insufficient (No Insufficient (No Insufficient (No Insufficient (No Insufficient (No PVI vs. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm of Sinus AF CV Mortality Hospitaliza- Symptoms/ Mixed Events Rhythm tions Control of AF Embolic Symptoms Events Including Stroke) Transcatheter SOE= SOE= SOE= All-Cause: SOE= SOE= SOE=Low (2 Stroke: SOE= SOE= PVI vs. Insufficient (2 Insufficient (15 Insufficient (6 SOE= Insufficient (No Insufficient (No studies, 152 Insufficient (2 Insufficient (No Transcatheter studies, 384 studies, 1,926 studies, 572 Insufficient (2 studies) studies) patients) studies, 361 studies) PVI With patients) patients) patients) studies, 405 No significant patients) Additional patients) difference Ablation Sites between arms Mixed: SOE= Other Than Cardiac: SOE= in 2 studies Insufficient (No CTI and CFAE studies) Insufficient (No and studies) Transcatheter PVI Involving all Four PVs vs. Transcatheter PVI Involving Arrhythmo- genic PVs Only Transcatheter SOE= SOE= SOE= SOE= CV: SOE= SOE= SOE= SOE= SOE= PVI Alone vs. Insufficient (No Insufficient (No Insufficient (2 Insufficient (No Insufficient (No Insufficient (No Insufficient (No Insufficient (No Insufficient (No Transcatheter studies) studies) studies, 217 studies) studies) studies) studies) studies) studies) PVI plus patients) Postablation AF: SOE=Low AADs (1 study, 110 patients) No difference between arms 116 Table 28. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm of Sinus AF CV Mortality Hospitaliza- Symptoms/ Mixed Events Rhythm tions Control of AF Embolic Symptoms Events Including Stroke) Surgical Maze SOE= SOE= SOE= All-cause: SOE= SOE= SOE= Stroke: SOE= SOE= vs. Standard of Insufficient (No Moderate (7 Insufficient (No SOE=Low (6 Insufficient (No Insufficient (1 Insufficient (No Insufficient (1 Insufficient (1 Care (Mitral studies) studies, 361 studies) studies, 384 studies) study, 30 studies) study, 30 study, 60 Valve Surgery) patients) patients) patients) patients) patients) OR 5. Summary of strength of evidence and effect estimates for KQ 5—pharmacological rhythm-control therapies Treatment Restoration of Maintenance Recurrence of All-Cause and AF and CV Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm of Sinus AF CV Mortality Hospitaliza- Symptoms/ Mixed Events Rhythm tions Control of AF Embolic Symptoms Events Including Stroke) Pharmaco- SOE= SOE= SOE= All-cause: SOE= SOE= SOE= Stroke: SOE= SOE= logical Therapy Insufficient (No Insufficient (1 Insufficient (4 SOE= Insufficient (No Insufficient (No Insufficient (1 Insufficient (1 Insufficient (No in Which studies) study, 168 studies, 414 Insufficient (1 studies) studies) study, 144 study, 168 studies) Electrical patients) patients) study, 168 patients) patients) Cardioversion patients) is a Key Mixed: SOE= Component of Cardiac: SOE= Insufficient (No the Treatment Insufficient (No studies) studies) Comparison of SOE= SOE=Low (9 SOE=Low (10 All-Cause: CV: SOE= Heart Failure: SOE=Low (2 Stroke: SOE= SOE= Pharmaco- Insufficient (No studies, 2,095 studies, 3,223 SOE= Insufficient (No SOE= studies, 1,068 Insufficient (2 Insufficient (No logical Agents studies) patients) patients) Insufficient (5 studies) Insufficient (No patients) studies, 1,068 studies) Amiodarone Amiodarone studies, 2,076 studies) No significant patients) appears better appears better patients) difference in AF: SOE=Low than sotalol, than (1 study, 403 AF Symptoms: either study Mixed: SOE= but no different dronedarone Cardiac: SOE= patients) SOE=Low (1 Insufficient (No from or sotalol, but Low (4 studies, Rate and study, 403 studies) propafenone no different 1,664 patients) patients) mean length of from No difference stay of AF No difference propafenone between study hospitalization between arms in were lower amiodarone arrhythmic with versus sotalol deaths amiodarone or propafenone than with sotalol or propafenone Abbreviations: AF=atrial fibrillation; CV=cardiovascular; KQ=Key Question; SOE=strength of evidence 118 KQ 6. Rate- Versus Rhythm-Control Therapies A total of 14 RCTs were included in our analysis, 12 that explored a rhythm-control strategy using pharmacological therapy versus a rate-control strategy, and 2 that compared a rhythm- control strategy with PVI versus a rate-control strategy that involved AVN ablation and implantation of a pacemaker in one case and rate-controlling medications in the other. Table 30 summarizes the strength of evidence for the rate- and rhythm-control therapies and evaluated outcomes. Details about the specific components of these ratings (risk of bias, consistency, directness, and precision) are available in the Results chapter. Summary of strength of evidence and effect estimate for KQ 6—rate- versus rhythm- control strategies Outcome Strength of Evidence and Effect Estimate Maintenance of Sinus Using AADs for Rhythm Control: Rhythm SOE=High (7 studies, 1,473 patients) OR 0. Since 6 of the 8 studies had ORs that crossed 1 (including 95% of the patients), and given significant heterogeneity, we assessed these studies as demonstrating no difference between rate- and rhythm- control strategies. CV Mortality Using AADs for Rhythm Control: SOE=Moderate (5 studies, 2,405 patients) OR 0. Summary of strength of evidence and effect estimate for KQ 6—rate- versus rhythm- control strategies (continued) Outcome Strength of Evidence and Effect Estimate Mixed Embolic Events Using AADs for Rhythm Control: Including Stroke SOE=Low (3 studies, 866 patients) OR 1. While some have argued that being in sinus rhythm is superior to being in AF, restoration and maintenance of sinus rhythm are not always easy, and the required therapies may pose harms, thus raising the fundamental question of whether a strategy focused only on controlling the ventricular rate as opposed to being focused on restoring and maintaining sinus rhythm may be safer and more effective. To further complicate treatment decisions, there are many pharmacological and nonpharmacological methods for controlling ventricular rate and for restoring and maintaining sinus rhythm; therefore, a complete understanding of the comparative safety and effectiveness of treatments within each strategy is needed for optimal treatment. Because our review was restricted to evidence published in 2000 or later, it is important to summarize what was known based on the evidence prior to 2000 to allow our findings to be viewed in context. As summarized in the 2001 AHRQ report on the Management of New Onset 25-27 Atrial Fibrillation, several medications were found to be efficacious in conversion of AF and subsequent maintenance of sinus rhythm. Unfortunately, as described below, these findings were largely based on comparisons with placebo or control therapy rather than with other active agents, and therefore the scope of this previous review is not directly applicable to that of this current comparative effectiveness review. Strong evidence of efficacy with a fairly large treatment effect size also existed for propafenone (OR 4. Quinidine had moderate evidence of efficacy and a modest treatment effect size compared with control treatment (OR 2. For maintenance of sinus rhythm, strong evidence of efficacy when compared with control treatment existed for quinidine (OR 4. For rate control, the design and outcome measures of included trials were too disparate for meta-analysis. In general, however, the evidence suggested that calcium channel blockers and some beta blockers were effective for controlling heart rate during exercise. Although the evidence for several individual therapies compared with control or placebo was strong, the lack of evidence supporting the comparative effectiveness of these therapies highlights the need for the current report. Published randomized controlled trials (RCTs), prior meta-analyses, and the above-mentioned Guidelines indicated that there did not appear to be a significant difference in outcomes of a rate- versus rhythm-control strategy; however, the results were driven primarily by one study (the Atrial 155 Fibrillation Follow-Up Investigation of Rhythm Management [AFFIRM] trial. Unlike AFFIRM and prior meta-analyses, in the current systematic review we included more patients and gathered data on multiple outcome measures from all studies comparing a rate-control strategy with a pharmacological rhythm-control strategy and also looked for studies using nonpharmacological rate- and rhythm-control treatments. We found no statistically significant difference in all-cause mortality or cardiovascular mortality between a rate-control strategy and a rhythm-control strategy using antiarrhythmic drugs, which is consistent with prior reviews. Our review extends beyond the findings of prior reviews, as it shows no significant difference in stroke or bleeding events between the strategies and shows a potential benefit of rhythm control for reduction in heart failure symptoms which, however, did not reach statistical significance. Our review confirms the findings of AFFIRM regarding all these outcomes. Confirming the findings related to heart failure symptoms and bleeding events is of particular interest due to the relatively small number of these events in AFFIRM. As expected, the rhythm-control strategy was associated with better maintenance of sinus rhythm than the rate-control strategy. Our review also looked specifically at comparisons of pharmacological and nonpharmacological rate-control therapies, including comparisons of lenient versus strict rate control.