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Biomedical subjects

J Deeks

Publications and source records attributed to J Deeks.

At least 19 recordsLinked to original sources
PubMed2001

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study.

OBJECTIVE: To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter. DESIGN: Before and after study. SETTING: UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999. SUBJECTS: People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates. MAIN OUTCOME MEASURES: Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates. RESULTS: Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change. CONCLUSION: Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.

Acetaminophen↗
PubMed2001

Temporal pitch perception and the binaural system.

Two experiments examined the relationship between temporal pitch (and, more generally, rate) perception and auditory lateralization. Both used dichotic pulse trains that were filtered into the same high (3,900-5,400-Hz) frequency region in order to eliminate place-of-excitation cues. In experiment 1, a 1-s periodic pulse train of rate Fr was presented to one ear, and a pulse train of rate 2Fr was presented to the other. In the "synchronous" condition, every other pulse in the 2Fr train was simultaneous with a pulse in the opposite ear. In each trial, subjects concentrated on one of the two binaural images produced by this mixture: they matched its perceived location by adjusting the interaural level difference (ILD) of a bandpass noise, and its rate/pitch was then matched by adjusting the rate of a regular pulse train. The results showed that at low Fr (e.g., 2 Hz), subjects heard two pulse trains of rate Fr, one in the "higher rate" ear, and one in the middle of the head. At higher Fr (>25 Hz) subjects heard two pulse trains on opposite sides of the midline, with the image on the higher rate side having a higher pitch than that on the "lower rate" side. The results were compared to those in a control condition, in which the pulses in the two ears were asynchronous. This comparison revealed a duplex region at Fr > 25 Hz, where across-ear synchrony still affected the perceived locations of the pulse trains, but did not affect their pitches. Experiment 2 used a 1.4-s 200-Hz dichotic pulse train, whose first 0.7 s contained a constant interaural time difference (ITD), after which the sign of the ITD alternated between subsequent pulses. Subjects matched the location and then the pitch of the "new" sound that started halfway through the pulse train. The matched location became more lateralized with increasing ITD, but subjects always matched a pitch near 200 Hz, even though the rate of pulses sharing the new ITD was only 100 Hz. It is concluded from both experiments that temporal pitch perception is not driven by the output of binaural mechanisms.

Functional Laterality↗
PubMed2000

A randomised, double-blind, controlled trial of the immunogenicity and tolerability of a meningococcal group C conjugate vaccine in young British infants.

A double-blind, randomised, controlled trial was conducted in 248 British infants to assess the immunogenicity and tolerability of three doses of a meningococcal group C/CRM (197) conjugate vaccine (Lederle Laboratories, USA) given at 2, 3 and 4 months. Control children received three doses of Hepatitis B vaccine (Engerix B(R); SmithKline Beecham). At 5 months of age, 100% of children receiving the conjugate vaccine had specific immunoglobulin G concentrations >2.0 microg/ml (n=116) compared with only 4% of control children (n=121). Those receiving the conjugate also had 2.5- and 1.6-fold higher geometric mean concentrations of PRP and diphtheria antibodies, respectively. The vaccine was well tolerated.

Antibodies, Bacterial↗
PubMed2000

Immunologic memory 5 years after meningococcal A/C conjugate vaccination in infancy.

Infant vaccination with meningococcal conjugates may provide long-term protection against disease. Antibody levels and immunologic memory were assessed in 5-year-old Gambian children who received meningococcal A/C conjugate vaccination (MenA/C) in infancy. At 2 years, they were randomized to receive a booster of MenA/C (conjugate group), meningococcal A/C polysaccharide (MPS group), or inactivated polio vaccine (IPV group). All groups were revaccinated with 10 microg MPS at 5 years of age, as were 39 previously unvaccinated age-matched control subjects. Before revaccination, titers were higher in the conjugate and MPS groups than in control subjects (P<.001); titers for the IPV group were similar to those for control subjects. Ten days after revaccination, the conjugate and IPV groups had similar serogroup C serum bactericidal antibody titers (3421 vs. 2790, respectively). These levels were significantly higher than those in the MPS (426) and control (485) groups (P<.001). Thus, immunologic memory was sustained for > or =5 years; however, MPS challenge at 2 years interfered with a subsequent memory response.

Adult↗
PubMed2000

Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial.

OBJECTIVE: To compare rates of local reactions associated with two needle sizes used to administer routine immunisations to infants. DESIGN: Randomised controlled trial. SETTING: Routine immunisation clinics in eight general practices in Buckinghamshire. PARTICIPANTS: Healthy infants attending for third primary immunisation due at 16 weeks of age: 119 infants were recruited, and 110 diary cards were analysed. INTERVENTIONS: Immunisation with 25 gauge, 16 mm, orange hub needle or 23 gauge, 25 mm, blue hub needle. MAIN OUTCOME MEASURES: Parental recordings of redness, swelling, and tenderness for three days after immunisation. RESULTS: Rate of redness with the longer needle was initially two thirds the rate with the smaller needle (relative risk 0.66 (95% confidence interval 0.45 to 0.99), P=0.04), and by the third day this had decreased to a seventh (relative risk 0.13 (0.03 to 0.56), P=0.0006). Rate of swelling with the longer needle was initially about a third that with the smaller needle (relative risk 0.39 (0.23 to 0.67), P=0.0002), and this difference remained for all three days. Rates of tenderness were also lower with the longer needle throughout follow up, but not significantly (relative risk 0.60 (0.29 to 1.25), P=0.17). CONCLUSIONS: Use of 25 mm needles significantly reduced rates of local reaction to routine infant immunisation. On average, for every five infants vaccinated, use of the longer needle instead of the shorter needle would prevent one infant from experiencing any local reaction. Vaccine manufacturers should review their policy of supplying the shorter needle in vaccine packs.

Confidence Intervals↗
PubMed2000

Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. Dyspepsia Review Group.

OBJECTIVES: To evaluate efficacy and cost effectiveness of Helicobacter pylori eradication treatment in patients with non-ulcer dyspepsia infected with H pylori. DESIGN: Systematic review of randomised controlled trials comparing H pylori eradication with placebo or another drug treatment. Results were incorporated into a Markov model comparing health service costs and benefits of H pylori eradication with antacid treatment over one year. DATA SOURCES: Six electronic databases were searched for randomised controlled trials from January 1966 to May 2000. Experts in the field, pharmaceutical companies, and journals were contacted for information on any unpublished trials. Trial reports were reviewed according to predefined eligibility and quality criteria. MAIN OUTCOME MEASURES: Relative risk reduction for remaining dyspeptic symptoms (the same or worse) at 3-12 months. Cost per dyspepsia-free month estimated from Markov model based on estimated relative risk reduction. RESULTS: Twelve trials were included in the systematic review, nine of which evaluated dyspepsia at 3-12 months in 2541 patients. H pylori eradication treatment was significantly superior to placebo in treating non-ulcer dyspepsia (relative risk reduction 9% (95% confidence interval 4% to 14%)), one case of dyspepsia being cured for every 15 people treated. H pylori eradication cost pound56 per dyspepsia-free month during first year after treatment. CONCLUSION: H pylori eradication may be cost effective treatment for non-ulcer dyspepsia in infected patients but further evidence is needed on decision makers' willingness to pay for relief of dyspepsia.

Antacids↗
PubMed2000

Prevention and early treatment of influenza in healthy adults.

INTRODUCTION: We present three systematic reviews carried out within the Cochrane Collaboration, focusing on a different influenza intervention in healthy adults: Vaccines; Ion Channel Inhibitor antivirals and Neuraminidase Inhibitor (NIs) antivirals. The objectives were to identify, retrieve and assess all studies evaluating the effects of these interventions in prophylaxis and early treatments of influenza and the frequency of adverse events. Additionally we present the results of the economic evaluation of effective alternatives in order to define the most cost-effective intervention. The economic evaluation is set in the context of the British Army. METHODS: Studies were identified using a standard Cochrane search strategy. Any randomised or quasi-randomised studies in healthy individuals aged 14-60 years were considered for inclusion in the systematic review. Those which met inclusion criteria were assessed for quality and their data meta-analysed. The economic model was constructed using Cost-effectiveness and Cost-utility study designs. RESULTS: Live aerosol vaccines reduced cases of clinical influenza A with virological confirmation (by serology and/or viral isolation) by 48% (95%CI: 24-64%), whilst recommended inactivated parenteral vaccines have an efficacy of 68% (95%CI: 49-79%). Vaccine effectiveness in reducing clinical influenza cases (i.e. without virological confirmation) was lower, with efficacies of 13 and 24% respectively. Use of the vaccine significantly reduced time off work, but only by 0.4 days (95%CI: 0. 1-0.8 days). Analysis of vaccines matching the circulating strain gave higher estimates of efficacy, whilst inclusion of all other vaccines reduced the efficacy. When compared to placebo for the prevention of influenza, oral amantadine was 61% (95%CI: 51-69%) efficacious (RR 0.39 - 95%CI: 0.31-0.49), and oral rimantadine was 64% (95%CI: 41-78%) efficacious (RR 0.36 -95%CI: 0.22-0.59). When compared to placebo for the treatment of influenza, oral amantadine significantly shortened duration of fever (by 1.00 days - 95%CI: 0. 73-1.29), and oral rimantadine significantly shortened duration of fever (by 1.27 days - 95%CI: 0.77-1.77). When compared to placebo, NIs were 74% (95%CIs: 50-87%) effective in preventing naturally occurring cases of clinically defined influenza. In a treatment role, NIs shortened the duration of symptoms by one day (Weighted Mean Difference - 1.0; 95%CIs: -1.3 to - 0.6) when a clinical case definition is used. The economic results show that in healthy adults, inactivated vaccines appear the best buy. CONCLUSIONS: If assessed from the point of view of effectiveness and efficiency, vaccines are undoubtedly the best preventive means for clinical influenza in healthy adults. However, when safety and quality of life considerations are included, parenteral vaccines have such low effectiveness and high incidence of trivial local adverse effects that the trade-off is unfavourable. This is so even when the incidence of influenza is high and adverse effect quality of life preferences are rated low. We reached similar conclusions for antivirals and NIs even at high influenza incidence levels. On current evidence we conclude in healthy adults aged 14-60 the most cost-effective option is not to take any action.

Adolescent↗
PubMed2000

Vaccines for preventing hepatitis B in health-care workers.

BACKGROUND: Hepatitis B causes acute and chronic liver disease and may be prevented by vaccination. OBJECTIVES: To assess the effectiveness and safety of plasma-derived vaccines against acute and chronic hepatitis B in health-care workers in protecting them from hepatitis B infection and its consequences. SEARCH STRATEGY: MEDLINE and Excerpta Medica Database (EMBASE) search using standard Cochrane strategy, Cochrane Library, full text searching of the journal "Vaccine", bibliography of retrieved studies and correspondence with authors, researchers and manufacturers. SELECTION CRITERIA: All original prospective randomised comparisons of yeast-derived vaccines and plasma-derived vaccines against no intervention, placebo, or vaccines against other disease (control vaccines). Assessment of trial quality was made according to: 1. generation of allocation schedule 2. measure(s) taken to conceal treatment allocation 3. drop-out of allocated health-care worker participants from the analysis of trial results 4. measures taken to implement double blinding Trial reports were blinded by removal of authors and their affiliation, journal reference, introduction, results, and discussion. DATA COLLECTION AND ANALYSIS: To assess efficacy the incidence rates of acute hepatitis B were observed in the surveillance of the vaccinated and control groups of the trials included in the review. Safety was assessed from side-effect rates, classified as systemic (malaise, nausea, fever, arthralgias, rash, headache) or local (induration and soreness at the site of the inoculation). MAIN RESULTS: Four trials fulfilling the criteria were identified and the data synthesised. All trials compared plasma-derived vaccines versus placebo. Differences in the settings (and level of incidence) between three of the trial settings and Dienstag's led us to stratify our comparison grouping the three trials performed in dialysis units together. After our stratification, the Desmyter, Smuzness and Crosnier group appears to be homogeneous (Chi-square = 0.11, degrees of freedom = 2). Our estimates of effectiveness and safety in the high risk group favour treatment, the OR for cases of HB being 0.34; 95% CI (0.21, 0.55). The analysis also revealed a non-significant trend towards benefit in the lower risk health-care workers (Dienstag trial, OR 0.26 (0.05, 1.30). Overall the evidence strongly favours vaccination (OR=0.33; 95% CI (0.21, 0.53)). There was no difference in the incidence and severity of side-effects between the two arms of the trials. We calculated that it was necessary to vaccinate between 145 (assuming a baseline rate of 10 cases/1000/year) and 7 (for a baseline rate of 200/1000/year) health-care workers with plasma-derived vaccines to avoid one case of hepatitis B. Completeness of trial reporting was not good with all four trials failing to report titre results on antibodies against hepatitis B surface antigen and hepatitis B core antigen in the placebo arms (correspondence with two of the four authors failed to shed light on the reasons for such an omission). All four trials achieved low scores in the four quality dimensions assessed (generation of allocation schedule, measure(s) taken to conceal treatment allocation, exclusion of allocated participants from the analysis of the trial and measures taken to implement and protect double blinding). Mean length of follow-up was 14.5 months. REVIEWER'S CONCLUSIONS: Plasma-derived vaccines appear to be efficacious and safe for use in high risk health-care workers, such as staff of renal dialysis and transplant units. There is some uncertainty concerning the effectiveness of the vaccine in lower risk health-care workers, although the trend is towards benefit. We found no evidence of a long-term protective effect due to the short follow-up time of the four trials included in this review. We found relatively poor standard of trial reporting, possibly related to the age of the trials.

Health Personnel↗
PubMed2000

Vaccines for preventing cholera.

BACKGROUND: Oral cholera vaccines (either killed whole cell or live recombinant vaccines) are newer alternatives to the parenteral vaccines which have been thought to confer only moderate and short-term immunity. OBJECTIVES: The objective of this review was to assess the effect of cholera vaccines in preventing cases of cholera and preventing deaths. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, Medline, Embase and reference lists of articles. We handsearched the journal Vaccine, contacted researchers in the field and manufacturers. SELECTION CRITERIA: Randomised and quasi-randomised studies comparing cholera vaccines (killed or live) with placebo, control vaccines or no intervention, or comparing types, doses or schedules of cholera vaccine. We included adults and children irrespective of immune status or special risk category. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of trial quality was done independently by two reviewers. MAIN RESULTS: Thirty-two trials were included. Seventeen efficacy trials of relatively good quality, testing parenteral and oral killed whole cell vaccines and involving over 2. 6 million adults, children and infants were included. Nineteen safety trials have been conducted for both types of killed whole cell vaccines and for live vaccines and have involved 11,459 people. For all types of vaccines compared to placebo, the relative risk of contracting cholera at 12 months was 0.49, 95% confidence interval 0. 41 to 0.59 (random effects model). This translates to an efficacy of 51%, 95% confidence interval 41% to 59%. Both parenteral and oral administration were relatively efficacious, but significant protection extended into the third year for oral killed whole cell vaccines. Children under 5 were only protected for up to a year, while older children or adults were protected for up to three years. Parenteral killed whole cell vaccines were associated with increased systemic and local adverse effects compared to placebo. Oral killed whole cell vaccines or oral live vaccines were not. REVIEWER'S CONCLUSIONS: Cholera killed whole cell vaccines appear to be relatively effective and safe. Live oral recombinant vaccines appear to be safe, but efficacy data are not available. Protection against cholera appears to persist for up to two years following a single dose of vaccine, and for three to four years with an annual booster.

Adult↗
PubMed2000

Vaccines for preventing anthrax.

BACKGROUND: Anthrax is an acute bacterial skin disease which may be fatal. Three anthrax vaccines are commercially available but their comparative effectiveness and safety is not clear. OBJECTIVES: The objective of this review was to assess the effects of human anthrax vaccines in healthy adults and children. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Medline, Embase and the reference lists of articles. We handsearched the journal Vaccine and contacted researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing anthrax vaccines with placebo, vaccines for other diseases or no intervention. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction was conducted independently by the six authors. MAIN RESULTS: Two trials involving 16,052 people were included. Both trials had methodological limitations. Compared to placebo, vaccination was associated with a reduced risk of contracting anthrax (relative risk 0.16, 95% confidence interval 0.07 to 0.35). Compared to placebo, the killed vaccine was associated with a higher incidence and severity of adverse effects (odds ratio 5.15, 95% confidence interval 2.28 to 11.61). Just over 5% of participants in the vaccine group reported adverse effects. The effectiveness of the vaccine does not appear to be influenced by the route of inoculation. REVIEWER'S CONCLUSIONS: Killed anthrax vaccines appear to be effective in reducing the risk of contracting anthrax with a relatively low rate of adverse effects. Further research should be restricted to testing new vaccines only.

Adult↗
PubMed2000

Neuraminidase inhibitors for preventing and treating influenza in healthy adults.

OBJECTIVES: Influenza is an acute respiratory infection associated with raised temperature, headache, muscle ache and cough. The objective of this review was to assess the effects of neuraminidase inhibitors (NIs) in preventing cases of influenza and shortening or reducing the severity of influenza in healthy adults. A further objective was to estimate the frequency of adverse effects associated with NI administration. SEARCH STRATEGY: We searched Medline, the Cochrane Acute Respiratory Infections Group trials register, the Cochrane Controlled Trials Register (CCTR), manufacturers' databases, Embase (1991 to 1998) and reference lists of articles in May 1999. We also contacted manufacturers, researchers in the field, and authors of studies evaluated in the review. SELECTION CRITERIA: Randomised or quasi-randomised placebo-controlled studies of NIs in healthy adults. Studies assessing protection or treatment from exposure to naturally occurring and experimental influenza were considered. The main outcomes were numbers and/or severity of influenza cases and the number and seriousness of adverse effects. DATA COLLECTION AND ANALYSIS: Two reviewers applied the inclusion criteria to the retrieved studies, assessed trial quality and extracted data. MAIN RESULTS: Eight trials with 1180 adults were included. Overall the methodological quality of the studies appeared to be good. As a preventive measure, NIs when compared to placebo were 74% effective (95% confidence interval 50% to 87%) in preventing naturally occurring cases of clinically defined influenza, and 60% effective (95% confidence interval 76% to 33%) in preventing cases of laboratory confirmed influenza. As a treatment, NIs shorten the duration of symptoms by one day - weighted mean difference 1 (95% confidence interval -1.3 to -0.6). The time gained in returning to normal activities is half a day - weighted mean difference -0.5 ( 95% confidence interval -1.1 to -0.1) for laboratory cases of influenza. The adverse event profile (local nasal irritation) of Zanamivir appears no better than placebo - odds ratio 1.19 ( 95% confidence interval 0.39 to 3.62). Compared with rimantadine in a preventive role, Oseltamivir has a significantly lower incidence of adverse effects and significantly higher incidence of nausea. For treatment, the adverse event profile shows that gastrointestinal symptoms are significantly worse in NIs than placebo - Peto odds ratio 2.32 ( 95% confidence interval 1.55 to 3.47). REVIEWER'S CONCLUSIONS: NIs are effective for the prevention and treatment of influenza. Overall NIs are safe, although Oseltamivir causes significant nausea.

Adult↗
PubMed2000

Beds, mattresses and cushions for pressure sore prevention and treatment.

OBJECTIVES: To assess the effectiveness of pressure relieving beds, mattresses and cushions (support surfaces) in the prevention and treatment of pressure sores. SEARCH STRATEGY: Searches of 19 databases, hand searching of journals, conference proceedings, and bibliographies. SELECTION CRITERIA: Randomised controlled trials evaluating support surfaces for the prevention or treatment of pressure sores. There was no restriction on articles based on language or publication status. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of study quality was undertaken by two reviewers independently. Trials with similar patients, comparisons, and outcomes were pooled. Where pooling was inappropriate, trials are discussed in a narrative review. MAIN RESULTS PREVENTION: 29 RCTs of support surfaces for pressure sore prevention were identified. Some high specification foam mattresses were more effective than 'standard' hospital foam mattresses in moderate-high risk patients. Pressure relieving mattresses in the operating theatre reduced the incidence of pressure sores post-operatively. The relative merits of alternating and constant low pressure, and of the different alternating pressure devices are unclear. Seat cushions and simple, constant low-pressure devices have not been adequately evaluated. Limited evidence suggests that low air loss beds reduce the incidence of pressure sores in intensive care. TREATMENT: 6 RCTs of support surfaces for pressure sore treatment were identified. There is good evidence that air-fluidised and low air loss beds improve healing rates. Seat cushions have not been adequately evaluated. 2 RCTs evaluated surfaces for both prevention and treatment in the same trial. REVIEWER'S CONCLUSIONS: PREVENTION - There is good evidence of the effectiveness of high specification foam over standard hospital foam, and pressure relief in the operating theatre. Treatment - There is good evidence of the effectiveness of air-fluidised and low air loss devices as treatments. Overall, however, it is impossible to determine the most effective surface for either prevention or treatment.

Beds↗
PubMed2000

Pharmacological interventions for non-ulcer dyspepsia.

BACKGROUND: The commonest cause of upper gastrointestinal symptoms is non-ulcer dyspepsia (NUD) and yet the pathophysiology of this condition has been poorly characterised and the optimum treatment is uncertain. It is estimated that pound450 million is spent on dyspepsia drugs in the UK each year. OBJECTIVES: This review aims to determine the effectiveness of six classes of drugs (antacids, histamine H2 antagonists, proton pump inhibitors, prokinetics, mucosal protecting agents and antimuscarinics) in the improvement of either the individual or global dyspepsia symptom scores and also quality of life scores patients with non-ulcer dyspepsia. SEARCH STRATEGY: Trials were located through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and text words, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and pharmaceutical companies. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing drugs of any of the six groups with each other or with placebo for non-ulcer dyspepsia (NUD). DATA COLLECTION AND ANALYSIS: Data were collected on dyspeptic symptom scores either individual or global symptom assessments and also quality of life scores and adverse effects. MAIN RESULTS: A total of 11775 citations were obtained. 144 trials were retrieved and 94 trials fulfilled our eligibility criteria. However, subsequent data extraction was not possible in 37 trials. Fifty trials were excluded as they did not meet our eligibility criteria. The final 57 trials were included in the final meta-analysis. Prokinetics (12 trials with dichotomous outcomes generating 829 patients; relative risk reduction [RRR] = 50%; 95% confidence intervals [CI] = 30 to 65%) and H2RAs (8 trials generating 1,125 patients; RRR = 30%; 95% CI = 4 to 48%) were significantly more effective than placebo. Proton pump inhibitors (4 trials generating 1,248 patients; RRR = 12%; 95% CI = -1 to 24%) and Bismuth salts (6 trials generating 311 patients; RRR = 40%; 95% CI = -3 to 65%) were superior to placebo but this was of marginal statistical significance. Antacids (one trial generating 109 patients; RRR = -2%; 95% CI = -36% to 24%) and sucralfate (two trials generating 246 patients; RRR = 29%; 95% CI = -40% to 64%) were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic result could be due to publication bias. The funnel plot of H2RAs did not show any evidence of publication bias but the quality of the trials was generally poor. REVIEWER'S CONCLUSIONS: There is some evidence that anti-secretory therapy may be effective in NUD. The trials evaluating prokinetic therapy are difficult to interpret as the meta-analysis result could have been due to publication bias. Further research using prokinetics and anti-secretory therapy is required before any firm conclusions can be reached. The effect of these drugs is likely to be small and many patients will need to take them on a long-term basis so the therapies assessed need to be inexpensive and well tolerated.

Dyspepsia↗
PubMed2000

Initial management strategies for dyspepsia.

BACKGROUND: This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. OBJECTIVES: To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) initial pharmacological therapy (including endoscopy for treatment failures) (b) early endoscopy (c) testing for Helicobacter pylori and endoscope only those positive (d) H.pylori eradication therapy with or without prior testing. SEARCH STRATEGY: Trials were located through electronic searches and extensive contact with trialists. SELECTION CRITERIA: All randomised controlled trials of dyspeptic patients presenting in primary care. DATA COLLECTION AND ANALYSIS: Data was collected on dyspeptic symptoms, quality of life and use of resources. MAIN RESULTS: Ten papers reporting 12 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (2 trials) and H2 receptor antagonists (3 trials), and of early endoscopy compared with initial acid suppression (3 trials) were pooled. PPIs were significantly more effective than both H2RA s and antacids. Relative risks (RR) and 95% CI were, for PPI: antacid 0.72 (0.64-0.80), PPI: H2RA 0.63 (0.47-0.85). Results for other drug comparisons were either absent or inconclusive. Early endoscopy was not more effective than initial prescribing (RR 0.90 (0.77-1.04), but current studies lack power. No eligible trials of H.pylori test and endoscopy or test and eradicate were found. REVIEWER'S CONCLUSIONS: PPIs are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease. The relative efficacy of H2RA and PPI is uncertain. Early investigation may benefit some patients with dyspepsia. The review will be updated shortly with several large trials that have recently been completed.

Anti-Bacterial Agents↗
PubMed2000

Eradication of helicobacter pylori for non-ulcer dyspepsia.

BACKGROUND: Helicobacter pylori (H pylori) is the main cause of peptic ulcer disease. The role of H pylori in non-ulcer dyspepsia is less clear. OBJECTIVES: To determine the effect of H pylori eradication on dyspepsia symptoms and quality of life scores in patients with non-ulcer dyspepsia. SEARCH STRATEGY: Trials were identified through electronic searches of the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL and SIGLE, using appropriate subject headings and keywords, searching bibliographies of retrieved articles, and through contacts with experts in the fields of dyspepsia and with pharmaceutical companies. SELECTION CRITERIA: All parallel group randomised controlled trials (RCTs) comparing drugs to eradicate H pylori with placebo or other drugs known not to eradicate H pylori for patients with non-ulcer dyspepsia. DATA COLLECTION AND ANALYSIS: Data were collected on individual and global dyspeptic symptom scores, quality of life measures and adverse effects. Dyspepsia outcomes were dichotomised into minimal/resolved versus same/worse symptoms. MAIN RESULTS: Seven randomised controlled trials were included in the systematic review. Five trials compared proton pump inhibitor dual or triple therapy with a proton pump inhibitor + placebo antibiotics, and evaluated dyspepsia at 6-12 months in 1,385 patients. H pylori eradication was significantly superior to placebo in treating non ulcer dyspepsia (relative risk reduction = 7%; 95% CI = 1% to 12%; p=0.02) and there was no significant heterogeneity between the studies. The number needed to treat to cure one case of dyspepsia = 19 (95% CI = 11 to 132). A further two trials compared Bismuth based H pylori eradication with an alternative pharmacological agent. These trials were smaller and had a shorter follow-up but suggested H pylori eradication was more effective than either H2 receptor antagonists or sucralfate in treating non-ulcer dyspepsia. REVIEWER'S CONCLUSIONS: H pylori eradication may be an effective therapy for H pylori positive non-ulcer dyspepsia. This result is not robust and further evidence on the efficacy of H pylori eradication in non ulcer dyspepsia would be helpful. The effect is modest and economic models would help establish whether this approach is cost-effective. This review will be updated as results from other ongoing trials (Malfertheiner 2000) are made available.

Anti-Bacterial Agents↗
PubMed2000

Suicide in psychiatric hospital in-patients. Risk factors and their predictive power.

BACKGROUND: Psychiatric hospital in-patients are known to be at high risk of suicide, yet there is little reliable knowledge of risk factors or their predictive power. AIMS: To identify risk factors for suicide in psychiatric hospital in-patients and to evaluate their predictive power in detecting people at risk of suicide. METHOD: Using a case-control design, 112 people who committed suicide while in-patients in psychiatric hospitals were compared with 112 randomly selected controls. Univariate analysis and multivariate analyses were used to estimate odds ratios and adjusted likelihood ratios. RESULTS: The rate of suicide in psychiatric in-patients was 13.7 (95% CI 11.7-16.1) per 10,000 admissions. There were five predictive factors with likelihood ratios > 2, following adjustment: planned suicide attempt, 4.1; actual suicide attempt, 4.9; recent bereavement, 4.0; presence of delusions, 2.3; chronic mental illness, 2.2; and family history of suicide, 4.6. On this basis, only two of the patients who committed suicide had a predicted risk of suicide above 5%. CONCLUSIONS: Although several factors were identified that were strongly associated with suicide, their clinical utility is limited by low sensitivity and specificity, combined with the rarity of suicide, even in this high-risk group.

Analysis of Variance↗