Evidence-Based Medicine

I also submitted the instructions in a file.

QUESTION #1 (3 pages = 1 ½ page each article)


Critical appraisal exercises relating to Studies:

1-. PART 1 INSTRUCTIONS: First article needs to be appraisal following the Rapid critical appraisal of a prognostic study following the format described.

IMPORTANT. Rapid critical appraisal of a prognostic study is explained starting on page 143. The answer must follow the format displayed at page 159-160. Example of how the final answer should be is displayed on page 196 where an article is Critically appraised type prognostic study – The Risk of Recurrent Venous Thromboembolism in Men and Women article study is answered. (pages 152–157). Please follow this format.


WHICH IS THE ARTICLE? : Choose any article similar to; The Risk of Recurrent Venous Thromboembolism in Men and Women article (Page 152-157) BUT DO NOT USE THIS ARTICLE.



Critical appraisal of Studies for a Prognosis question



When we critically appraise an article about a prognosis question consider

(a) decide whether the internal validity of the study is sufficient to allow firm conclusions (all studies have some flaws; but are these flaws bad enough to discard the study?)

(b) if the study is sufficiently valid, look at and interpret the results — what are the sensitivity, specificity and predictive values for the index test?




2-. PART 2 INSTRUCTIONS: Rapid critical appraisal of a diagnostic test accuracy is explained starting on page 161. Second article needs to be appraised following the Rapid critical appraisal of studies for a Diagnostic test accuracy question following the format described on pages 172-173 of the book. Example of how this appraisal must be answer is on page 197 where they answered the article Whispered voice: The best test for screening for hearing impairment in general practice? (Page 169-171)



WHICH IS THE ARTICLE? : Choose any article similar to Whispered voice: The best test for screening for hearing impairment in general practice? (PAGE 169-171) where we can appraisal a diagnostic test accuracy question BUT DO NOT USE THIS ARTICLE.



Critical appraisal of studies for a Diagnostic test accuracy question.



When we critically appraise an article about a diagnostic test consider:


(a) decide whether the internal validity of the study is sufficient to allow firm conclusions (all studies have some flaws; but are these flaws bad enough to discard the study?)

(b) if the study is sufficiently valid, look at and interpret the results — what are the sensitivity, specificity and predictive values for the index test?





QUESTION #2 ( 2 pages)


Reflections and further information. Analysis of ongoing improvement through a diary of a reflective practitioner. Complete the box questions. We need to have a quick review of step 4 of the book named Reflections and further information (starting on page 175) and give them an opinion of the following questions stated in box questions.:


Are you asking any questions at all?

What is your success rate in asking answerable questions?

How is your searching going?

Are you critically appraising your search results?

Are you applying your evidence in clinical practice?

Are you sharing your efforts with others?



QUESTION #3 (2 pages)


Submit a short paper (2 pages ) as their final assignment on a case of interest from their practice with application of EBM principles acquired in this course. Choose clinical situation that we as a nursing student can apply EBM principles. Write it in 2 pages.












QUESTION # 4 (2 pages= (1 ½ page part 1), and (½ page part 2)



1-. PART 1-.Please make the outline specific for my topic and not a generic outline for how to write a paper (displayed). I already have done the annotated bibliography. I copy the abstract of 12 articles that I will use for my 22 pages paper at the bottom. I need again make my outline more specific for the topic FOLLOWING the generic outline displayed below. You just complete the outline or make another one.










Recent immigrant refers to a person who obtained a landed immigrant or permanent resident status up to five years prior to a given census year.



I- Introduction (2-3 paragraphs)


B-.Statement of the problem why

C-.History of the problem


II-.Body Section 1 (4-6 paragraphs)

A-.Extend of the problem/ How bad is it?

1-.What has happened?

2-Why we should be concerned?

B-.Who is affected? /How are they affected?




III-Body Section 2 ( 3-4 paragraphs)

A-.Cause/ Effect

1-.Because of this problem, this happened ……

B-.Repercussions of the problem

1-.If we do not solve, this will happen……

IV-.Body Section 3 (1-3 paragraphs)

A-.Possible solutions

1-.What will work

2-.What will not work

3-.Possible oppositions

V-.Conclusions (1-2 paragraphs)

A-.Relate back to intro (story/quote/question)

B-.Restate thesis/clincher




2-.PART 2-. Short paragraph (1/2 page) answer why these articles are relevant to the topic questions.






Cain KP, Benoit SR, Winston CA, Mac Kenzie WR. Tuberculosis among foreign-born persons in the United States. JAMA. 2008 Jul 23;300(4):405-12. doi: 10.1001/jama.300.4.405. PMID: 18647983



Context: Foreign-born persons accounted for 57% of all tuberculosis (TB) cases in the United States in 2006. Current TB control strategies have not sufficiently addressed the high levels of TB disease and latent TB infection in this population.

Objective: To determine the risk of TB disease and drug-resistant TB among foreign-born populations and the potential impact of adding TB culture to overseas screening procedures for foreign-born persons entering the United States.

Design, setting, and participants: Descriptive epidemiologic analysis of foreign-born persons in the United States diagnosed with TB from 2001 through 2006.

Main outcome measures: TB case rates, stratified by time since US entry, country of origin, and age at US entry; anti-TB drug-resistance patterns; and characteristics of TB cases diagnosed within 3 months of US entry.

Results: A total of 46,970 cases of TB disease were reported among foreign-born persons in the United States from 2001 through 2006, of which 12,928 (28%) were among recent entrants (within 2 years of US entry). Among the foreign-born population overall, TB case rates declined with increasing time since US entry, but remained higher than among US-born persons–even more than 20 years after arrival. In total, 53% of TB cases among foreign-born persons occurred among the 22% of the foreign-born population born in sub-Saharan Africa and Southeast Asia. Isoniazid resistance was as high as 20% among recent entrants from Vietnam and 18% for recent entrants from Peru. On average, 250 individuals per year were diagnosed with smear-negative, culture-positive TB disease within 3 months of US entry; 46% of these were from the Philippines or Vietnam.

Conclusion: The relative yield of finding and treating latent TB infection is particularly high among individuals from most countries of sub-Saharan Africa and Southeast Asia







Lönnroth K, Mor Z, Erkens C, Bruchfeld J, Nathavitharana RR, van der Werf MJ, Lange C. Tuberculosis in migrants in low-incidence countries: epidemiology and intervention entry points. Int J Tuberc Lung Dis. 2017 Jun 1;21(6):624-637. doi: 10.5588/ijtld.16.0845. PMID: 28482956.




As tuberculosis (TB) rates continue to decline in native populations in most low TB incidence countries, the proportion of TB patients born outside their country of residence (‘foreign-born’) increases. Some low-incidence countries have experienced a substantial increase in TB rates related to recent increases in the number of asylum seekers and other migrants from TB-endemic countries. However, average TB rates among the foreign-born in low-incidence countries declined moderately in 2009-2015. TB in foreign-born individuals is commonly the result of reactivation of latent infection with Mycobacterium tuberculosis acquired outside the host country. Transmission is generally low in low-incidence countries, and transmission from migrants to the native population is often modest. Variations in levels and trends in TB notifications among the foreign-born are likely explained by differences and fluctuations in the number and profile of migrants, as well as by variations in TB control, health and social policies in the host countries. To optimise TB care and prevention in migrants from endemic to low-incidence countries, we propose a framework for identifying possible TB care and prevention interventions before, during and after migration. Universal access to high-quality care along the entire migration pathway is critical. Screening for active TB and latent tuberculous infection should be tailored to the TB epidemiology, adapted to the needs of specific migrant groups and linked to treatment. Ultimately, the long-term TB elimination goal can be reached only if global health and socio-economic inequalities are dramatically reduced. Low-incidence countries, most of which are among the wealthiest nations, need to contribute through international assistance.



Liu Y, Painter JA, Posey DL, Cain KP, Weinberg MS, Maloney SA, Ortega LS, Cetron MS. Estimating the impact of newly arrived foreign-born persons on tuberculosis in the United States. PLoS One. 2012;7(2):e32158. doi: 10.1371/journal.pone.0032158. Epub 2012 Feb 27. PMID: 22384165; PMCID: PMC3287989.



Among approximately 163.5 million foreign-born persons admitted to the United States annually, only 500,000 immigrants and refugees are required to undergo overseas tuberculosis (TB) screening. It is unclear what extent of the unscreened nonimmigrant visitors contributes to the burden of foreign-born TB in the United States.

Methodology/Principal Findings

We defined foreign-born persons within 1 year after arrival in the United States as “newly arrived”, and utilized data from U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, and World Health Organization to estimate the incidence of TB among newly arrived foreign-born persons in the United States. During 2001 through 2008, 11,500 TB incident cases, including 291 multidrug-resistant TB incident cases, were estimated to occur among 20,989,738 person-years for the 1,479,542,654 newly arrived foreign-born persons in the United States. Of the 11,500 estimated TB incident cases, 41.6% (4,783) occurred among immigrants and refugees, 36.6% (4,211) among students/exchange visitors and temporary workers, 13.8% (1,589) among tourists and business travelers, and 7.3% (834) among Canadian and Mexican nonimmigrant visitors without an I-94 form (e.g., arrival-departure record). The top 3 newly arrived foreign-born populations with the largest estimated TB incident cases per 100,000 admissions were immigrants and refugees from high-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of ≥100 cases/100,000 population/year; 235.8 cases/100,000 admissions, 95% confidence interval [CI], 228.3 to 243.3), students/exchange visitors and temporary workers from high-incidence countries (60.9 cases/100,000 admissions, 95% CI, 58.5 to 63.3), and immigrants and refugees from medium-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of 15–99 cases/100,000 population/year; 55.2 cases/100,000 admissions, 95% CI, 51.6 to 58.8).


Newly arrived nonimmigrant visitors contribute substantially to the burden of foreign-born TB in the United States. To achieve the goals of TB elimination, direct investment in global TB control and strategies to target nonimmigrant visitors should be considered



Menzies HJ, Winston CA, Holtz TH, Cain KP, Mac Kenzie WR. Epidemiology of tuberculosis among US- and foreign-born children and adolescents in the United States, 1994-2007. Am J Public Health. 2010 Sep;100(9):1724-9. doi: 10.2105/AJPH.2009.181289. Epub 2010 Jul 15. PMID: 20634457; PMCID: PMC2920976.


Objectives. We examined trends in tuberculosis (TB) cases and case rates among US- and foreign-born children and adolescents and analyzed the potential effect of changes to overseas screening of applicants for immigration to the United States.

Methods. We analyzed TB case data from the National Tuberculosis Surveillance System for 1994 to 2007.

Results. Foreign-born children and adolescents accounted for 31% of 18 659 reported TB cases in persons younger than age 18 years from 1994 to 2007. TB rates declined 44% among foreign-born children and adolescents (20.3 per 100 00 to 11.4 per 100 000 population) and 48% (2.1 per 100 000 to 1.1 per 100 000) among those who were born in the United States. Rates were nearly 20 times as high among foreign-born as among US-born adolescents. Among foreign-born children and adolescents with known month of US entry (88%), more than 20% were diagnosed with TB within 3 months of entry.

Conclusions. Marked disparities in TB morbidity persist between foreign- and US-born children and adolescents. These disparities and the high proportion of TB cases diagnosed shortly after US entry suggest a need for enhanced pre- and postimmigration screening




Tsang CA, Langer AJ, Navin TR, Armstrong LR. Tuberculosis Among Foreign-Born Persons Diagnosed ≥10 Years After Arrival in the United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 24;66(11):295-298. doi: 10.15585/mmwr.mm6611a3. PMID: 28333913; PMCID: PMC5657888.




What is already known about this topic?

Tuberculosis (TB) screening in the United States of persons from high TB–prevalence countries has historically focused on newly arrived persons. U.S. TB cases typically occur among persons who were infected years before experiencing disease. Persons with latent TB infection have a 5%–10% lifetime risk for developing TB disease in the United States.


What is added by this report?

Beginning in 2013, the number of TB diagnoses among foreign-born persons ≥10 years after U.S. arrival (2,823) has exceeded those among persons <10 years after U.S. arrival (2,814). In 2015, among 5,763 TB cases diagnosed in foreign-born persons in the United States for whom the date of U.S. entry was known, 2,922 (51%) were diagnosed in persons ≥10 years after U.S. arrival. Foreign-born persons who received a TB diagnosis ≥10 years after U.S. arrival had greater odds of being aged ≥40 years, residing in a long-term care facility at diagnosis, and having non-HIV–related immunocompromising conditions.


\What are the implications for public health practice?

Promoting testing for TB infection as part of routine primary care among groups at high risk is crucial for advancing TB prevention and elimination initiatives in the United States. Emphasis should be focused on persons who have lived in countries with high TB prevalence, including persons who have resided in the United States for ≥10 years



Baker BJ, Winston CA, Liu Y, France AM, Cain KP. Abrupt Decline in Tuberculosis among Foreign-Born Persons in the United States. PLoS One. 2016 Feb 10;11(2):e0147353. doi: 10.1371/journal.pone.0147353. PMID: 26863004; PMCID: PMC4749239.


Abstract and Figures

While the number of reported tuberculosis (TB) cases in the United States has declined over the past two decades, TB morbidity among foreign-born persons has remained persistently elevated. A recent unexpected decline in reported TB cases among foreign-born persons beginning in 2007 provided an opportunity to examine contributing factors and inform future TB control strategies. We investigated the relative influence of three factors on the decline: 1) changes in the size of the foreign-born population through immigration and emigration, 2) changes in distribution of country of origin among foreign-born persons, and 3) changes in the TB case rates among foreign-born subpopulations. Using data from the U.S. National Tuberculosis Surveillance System and the American Community Survey, we examined TB case counts, TB case rates, and population estimates, stratified by years since U.S. entry and country of origin. Regression modeling was used to assess statistically significant changes in trend. Among foreign-born recent entrant



Armstrong LR, Winston CA, Stewart B, Tsang CA, Langer AJ, Navin TR. Changes in tuberculosis epidemiology, United States, 1993-2017. Int J Tuberc Lung Dis. 2019 Jul 1;23(7):797-804. doi: 10.5588/ijtld.18.0757. PMID: 31439110; PMCID: PMC7052520.




After a steady decline for 20 years, the pace of decline of TB incidence in the United States has slowed.


Trends in TB incidence rates and case counts since 1993 were analyzed using national US surveillance data. Patient characteristics reported during 2014–2017 were compared with those for 2010–2013.


TB rates and case counts have slowed to an annual decline 2.2% (95% confidence interval (CI): –3.4– –1.0) and 1.5% (95% CI: –2.7– –0.3) respectively, since 2012, with declines among US-born persons and no change among non-US–born persons. Overall, persons with TB diagnosed during 2014–2017 were older, more likely to have combined pulmonary and extrapulmonary disease compared with exclusively extrapulmonary disease, more likely to be of nonwhite race, and less likely to be human immunodeficiency virus-positive, or have cavitary pulmonary disease. During 2014–2017, non-US–born persons with TB were more likely to have diabetes while the US-born were more likely to have smear positive TB and use noninjecting drugs.


Changes in epidemiologic trends are likely to affect TB incidence for coming decades. CDC has called for increased attention toward preventing TB through detection and treatment of latent TB infection.




Cowger TL, Wortham JM, Burton DC. Epidemiology of tuberculosis among children and adolescents in the USA, 2007-17: an analysis of national surveillance data. Lancet Public Health. 2019 Oct;4(10):e506-e516. doi: 10.1016/S2468-2667(19)30134-3. Epub 2019 Aug 21. PMID: 31446052.


Background: Understanding tuberculosis epidemiology among children and adolescents informs treatment and prevention efforts, and efforts to eliminate disparities in tuberculosis incidence and mortality. We sought to describe the epidemiology of children and adolescents with tuberculosis disease in the USA, including tuberculosis incidence rates by parental country of birth and for US territories and freely associated states, which have not been previously described.

Methods: We analysed data for children aged younger than 15 years and adolescents aged 15-17 years with tuberculosis disease reported to the National Tuberculosis Surveillance System during 2007-17, and calculated tuberculosis incidence rates using population estimates from the US Census Bureau.

Findings: During 2010-17, 6072 tuberculosis cases occurred among children and adolescents; of these, 5175 (85%) of 6072 occurred in the 50 US states or the District of Columbia and 897 (15%) of 6072 in US-affiliated islands. In US states, 3520 (68%) of 5175 cases occurred among US-born people overall, including 2977 (76%) of 3896 children and 543 (42%) of 1279 adolescents. The incidence rate among children and adolescents was 1·0 per 100 000 person-years during 2007-17 and declined 47·8% (95% CI -51·4 to -44·1) during this period. We observed disproportionately high tuberculosis rates among children and adolescents of all non-white racial or ethnic groups, people living in US-affiliated islands, and children born in or with parents from tuberculosis-endemic countries.

Interpretation: Overall, tuberculosis incidence among children and adolescents in the USA is low and steadily declining, but additional efforts are needed to eliminate disparities in incidence and mortality.

Funding: US Centers for Disease Control and Prevention



Scandurra G, Degeling C, Douglas P, Dobler CC, Marais B. Tuberculosis in migrants – screening, surveillance and ethics. Pneumonia (Nathan). 2020 Sep 5;12:9. doi: 10.1186/s41479-020-00072-5. PMID: 32923311; PMCID: PMC7473829.



Tuberculosis (TB) is the leading infectious cause of human mortality and is responsible for nearly 2 million deaths every year. It is often regarded as a ‘silent killer’ because it predominantly affects the poor and marginalized, and disease outbreaks occur in ‘slow motion’ compared to Ebola or coronavirus 2 (COVID-19). In low incidence countries, TB is predominantly an imported disease and TB control in migrants is pivotal for countries to progress towards TB elimination in accordance with the World Health Organisations (WHO’s) End TB strategy. This review provides a brief overview of the different screening approaches and surveillance processes that are in place in low TB incidence countries. It also includes a detailed discussion of the ethical issues related to TB screening of migrants in these settings and the different interests that need to be balanced. Given recognition that a holistic approach that recognizes and respects basic human rights is required to end TB, the review considers the complexities that require consideration in low-incidence countries that are aiming for TB elimination.

Keywords: Tuberculosis, TB, Migration, Migrants, Review, Pre-screening, Ethics




Facciolà A, Visalli G, D’Andrea G, Di Pietro A. The burden of Tuberculosis in a low-incidence territory: contribution of foreign population in the disease epidemiology. New Microbiol. 2020 Sep 4;43(4). Epub ahead of print. PMID: 33021317.



In recent years, a decrease in the incidence of tuberculosis (TB) has been recorded worldwide. However, an increase in TB cases has been reported in foreign people living in low-incidence countries, with an increase in extrapulmonary TB (EPTB) in the western region of the world. In the present work, a retrospective study was conducted in two Italian infectious diseases wards to evaluate the clinical characteristics of TB admission in the time period 2013–2017. A significant increase in TB was shown in the study period: 166 (71% males) patients with TB were enrolled, with ~70% coming from outside Italy (30% from Africa, 25% from Europe, and 13% from Asia and South America). Compared to foreign people, Italians were significantly older (71.5 (interquartile range, IQR: 44.5–80.0) vs. 30 (IQR: 24–40) years; p < 0.0001) more immunocompromised (48% vs. 17%; p < 0.0001), and affected by comorbidities (44% vs. 14%; p < 0.0001). EPTB represented 37% of all forms of the disease, and it was more incident in subjects coming from Africa than in those coming from Europe (39.3% vs. 20%, respectively). In logistic regression analysis, being European was protective (odd ratio, OR (95% CI): 0.2 (0.1–0.6); p = 0.004) against the development of EPTB forms. In conclusion, an increase in the rate of TB diagnosis was documented in two Italian reference centers in the period 2013–2017, with 39% of EPTB diagnosed in patients from outside Europe.

Keywords: tuberculosis, pulmonary tuberculosis, extrapulmonary tuberculosis, foreign people





Menzies NA, Hill AN, Cohen T, Salomon JA. The impact of migration on tuberculosis in the United States. Int J Tuberc Lung Dis. 2018 Dec 1;22(12):1392-1403. doi: 10.5588/ijtld.17.0185. PMID: 30606311; PMCID: PMC6353558.



in English, French, Spanish

Due to greater exposure to Mycobacterium tuberculosis infection before migration, migrants moving to low-incidence settings can experience substantially higher tuberculosis (TB) rates than the native-born population. This review describes the impact of migration on TB epidemiology in the United States, and how the TB burden differs between US-born and non-US-born populations. The United States has a long history of receiving migrants from other parts of the world, and TB among non-US-born individuals now represents the majority of new TB cases. Based on an analysis of TB cases among individuals from the top 30 countries of origin in terms of non-US-born TB burden between 2003 and 2015, we describe how TB risks vary within the non-US-born population according to age, years since entry, entry year, and country of origin. Variation along each of these dimensions is associated with more than 10-fold differences in the risk of developing active TB, and this risk is also positively associated with TB incidence estimates for the country of origin and the composition of the migrant pool in the entry year. Approximately 87 000 lifetime TB cases are predicted for the non-US-born population resident in the United States in 2015, and 5800 lifetime cases for the population entering the United States in 2015



CDC. Tuberculosis Among Foreign-Born Persons Entering the United States-Recommendations of the Advisory Committee For Elimination of Tuberculosis. MMWR 1990;39 (RR18);1-13,18-21. 2001


In 1989, the Department of Health and Human Services Advisory Committee for Elimination of Tuberculosis published a plan for eliminating tuberculosis from the United States by the year 2010. This plan gives a top priority to implementing strategies to prevent tuberculosis in high-incidence groups. Foreign-born persons (as a group) residing in the United States have higher rates of tuberculosis than persons born in the United States. In 1989, the overall U.S. tuberculosis rate was 9.5 per 100,000 population; for foreign-born persons arriving in the United States, the estimated case rate was 124 per 100,000. In the period 1986-1989, 22\% (20,316) of all reported cases of tuberculosis occurred in the foreign-born population. A majority of foreign-born persons who develop tuberculosis do so within the first 5 years after they enter the United States.

The ACET recommends that all foreign-born persons applying for permanent entry into the United States continue to be screened for disease. Deficiencies in the current screening methods should be corrected. The policy requiring that persons found to have infectious tuberculosis (known or suspected) be prevented from entering the country until treatment has rendered them noninfectious should be continued; however, persons with noninfectious tuberculosis should be permitted to enter the United States. Tuberculin skin testing and preventive therapy programs for foreign-born persons must be expanded both overseas and domestically if the goal of eliminating tuberculosis from the United States by the year 2010 is to be met.

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