Biomedical subjects

J Picot

Publications and source records attributed to J Picot.

15 recordsLinked to original sources

PubMed2006

A systematic review of the clinical effectiveness of donepezil, rivastigmine and galantamine on cognition, quality of life and adverse events in Alzheimer's disease.

BACKGROUND: The use of cholinesterase inhibitors for Alzheimer's disease (AD) is currently being appraised by the National Institute for Clinical Evidence (NICE). This article provides the latest evidence that NICE will be using as part of this appraisal process. OBJECTIVE: To provide a systematic review of the best quality evidence of the effects of donepezil, rivastigmine and galantamine on cognition, quality of life and adverse events in people with mild to moderately-severe AD. DESIGN: Electronic databases were searched, references of all retrieved articles were checked, and experts were contacted for advice, peer review and to identify additional references. Randomised controlled trials (RCTs) were included if they fulfilled pre-specified criteria. Data were synthesised through a narrative review. RESULTS: Twenty-six RCTs that compared any one of the cholinesterase inhibitors with either a control group or with another cholinesterase inhibitor were included. The quality of reporting and methodology was varied. Treatment with donepezil, rivastigmine or galantamine resulted in significantly better cognitive performance using the ADAS-cog scale when compared with placebo. These findings were generally supported using the MMSE scale. Results from head to head comparisons were limited by the low number of studies and the study quality; generally showing no robust support for any one drug. Few studies evaluated quality of life. Adverse events were generally related to the gastrointestinal system, with a tendency for these to be more common in the treatment arms. CONCLUSIONS: The cholinesterase inhibitors donepezil, rivastigmine, and galantamine can delay cognitive impairment in patients with mild to moderately-severe AD for at least 6 months duration.

Alzheimer Disease↗

PubMed2006

The clinical and cost-effectiveness of donepezil, rivastigmine, galantamine and memantine for Alzheimer's disease.

OBJECTIVES: To provide an update review of the best quality evidence for the clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine for mild to moderately severe Alzheimer's disease (AD) and of memantine for moderately severe to severe AD. DATA SOURCES: Electronic databases, experts in the field and manufacturer submissions to the National Institute for Health and Clinical Excellence (NICE). REVIEW METHODS: A systematic review of the literature and an economic evaluation were undertaken. The quality of included randomised controlled trials (RCTs) was assessed using criteria developed by the NHS Centre for Reviews and Dissemination. An outline assessment of economic evaluations was undertaken using a standard checklist. The clinical and cost-effectiveness data were synthesised through a narrative review with full tabulation of the results of included studies. Where appropriate, meta-analysis of data was undertaken. RESULTS: For mild to moderately severe AD, the results of the study suggested that all three treatments were beneficial when assessed using cognitive outcome measures. Global outcome measures were positive for donepezil and rivastigmine, but mixed for galantamine. Results for measures of function were mixed for donepezil and rivastigmine, but positive for galantamine. Behaviour and mood measures were mixed for donepezil and galantamine, but showed no benefit for rivastigmine. For memantine, two published RCTs were included; in one of these trials the participants were already being treated with donepezil. The results suggest that memantine is beneficial when assessed using functional and global measurements. The effect of memantine on cognitive and behaviour and mood outcomes is, however, less clear. Literature on the cost-effectiveness of donepezil, rivastigmine and galantamine was dominated by industry-sponsored studies, and studies varied in methods and results. Of the three UK studies, two report donepezil as not cost-effective, whereas a third study reports an additional cost (1996 pounds sterling) of between 1200 pounds sterling and 7000 pounds sterling per year in a non-severe AD health state (concerns over these estimates are raised, suggesting that they may underestimate the true cost-effectiveness of donepezil). Cost-effectiveness analysis undertaken in this review suggests that donepezil treatment has a cost per quality-adjusted life-year (QALY) in excess of 80,000 pounds sterling, with donepezil treatment reducing the mean time spent in full-time care (delays progression of AD) by 1.42-1.59 months (over a 5-year period). From four published cost-effectiveness studies, two UK studies report additional costs associated with rivastigmine treatment. Cost-effectiveness analysis undertaken in the current review suggests that rivastigmine treatment has a cost per QALY in excess of 57,000 pounds sterling, with rivastigmine treatment reducing the mean time spent in full-time care (delays progression) by 1.43-1.63 months (over a 5-year period). From five published cost-effectiveness studies, one UK study reports a cost per QALY of 8693 pounds sterling for 16-mg galantamine treatment and 10,051 pounds sterling for 24-mg galantamine treatment (concerns raised suggest that this may underestimate the true cost-effectiveness of galantamine). Cost-effectiveness analysis undertaken in the present review suggests that galantamine treatment has a cost per QALY in excess of 68,000 pounds sterling, with galantamine reducing the time spent in full-time care (delays progression) by 1.42-1.73 months (over a 5-year period). From two published cost-effectiveness studies, one reports analysis for the UK, finding that memantine treatment results in cost savings and benefits in terms of delaying disease progression (concerns raised suggest that this may underestimate the true cost-effectiveness of memantine). In the current review, the cost-effectiveness of memantine has not been modelled separately, but where alternative parameter inputs on the cost structure and utility values have been used in a reanalysis using the industry model, the cost-effectiveness is reported at between 37,000 pounds sterling and 52,000 pounds sterling per QALY, with this alternative analysis still based on what is regarded as an optimistic or favourable effectiveness profile for memantine. CONCLUSIONS: Although results from the clinical effectiveness review suggest that these treatments may be beneficial, a number of issues need to be considered when assessing the results of the present review, such as the characteristics of the participants included in the individual trials, the outcome measures used, the length of study duration, the effects of attrition and the relationship between statistical significance and clinical significance. Many included trials were sponsored by industry. For donepezil, rivastigmine and galantamine, the cost savings associated with reducing the mean time spent in full-time care do not offset the cost of treatment sufficiently to bring estimated cost-effectiveness to levels generally considered acceptable by NHS policy makers. It is difficult to draw conclusions on the cost-effectiveness of memantine; it is suggested that further amendments to the potentially optimistic industry model (measure of effect) would offer higher cost per QALY estimates. Future research should include: information on the quality of the outcome measures used; development of quality of life instruments for patients and carers; studies assessing the effects of these interventions of durations longer than 12 months; comparisons of benefits between interventions; and research on the prediction of disease progression.

Aged↗

PubMed2005

Physical training for asthma.

BACKGROUND: Physical training programmes have been designed for asthmatic subjects with the aim of improving physical fitness, neuromuscular coordination and self-confidence. Habitual physical activity increases physical fitness and lowers ventilation during mild and moderate exercise thereby reducing the likelihood of provoking exercise induced asthma. Exercise training may also reduce the perception of breathlessness through a number of mechanisms including strengthening respiratory muscles. Subjectively, many asthmatics report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. OBJECTIVES: The purpose of this review was to assess evidence for the efficacy and effectiveness of physical training in asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register, SportDiscus and the Science Citation Index up to May 2005. SELECTION CRITERIA: Randomised trials in asthmatic subjects undertaking physical training. Subjects had to be eight years and older. Physical training had to be undertaken for at least 20 to 30 minutes, two to three times a week, over a minimum of four weeks. DATA COLLECTION AND ANALYSIS: Eligibility for inclusion and quality of trials were assessed independently by two reviewers. MAIN RESULTS: Thirteen studies (455 participants) were included in this review. Physical training had no effect on resting lung function or the number of days of wheeze. The results of this review have shown that lung function and wheeze is not worsened by physical training in patients with asthma. Physical training improved cardiopulmonary fitness as measured by an increase in maximum oxygen uptake of 5.4 ml/kg/min (95% confidence interval 4.2 to 6.6) and maximum expiratory ventilation 6.0 L/min (95% confidence interval 1.5 to 10.4). There were no data concerning quality of life measurements. AUTHORS' CONCLUSIONS: In people with asthma, physical training can improve cardiopulmonary fitness without changing lung function. It is not known whether improved fitness is translated into improved quality of life. It is comforting to know that physical training does not have an adverse effect on lung function and wheeze in patients with asthma. Therefore, there is no reason why patients with asthma should not participate in regular physical activity.

Asthma↗

PubMed2004

Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD. SEARCH STRATEGY: An initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases. An updated search was conducted in September 2003. SELECTION CRITERIA: Randomised controlled trials comparing NPPV plus usual medical care (UMC) versus UMC alone were selected. Trials needed to recruit adult patients admitted to hospital with respiratory failure due to an exacerbation of COPD and with PaCO(2) > 6 kPa (45 mmHg). DATA COLLECTION AND ANALYSIS: Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted the data. MAIN RESULTS: Fourteen studies were included in the review. NPPV resulted in decreased mortality (Relative Risk 0.52; 95%CI 0.35, 0.76), decreased need for intubation (RR 0.41; 95%CI 0.33, 0.53), reduction in treatment failure (RR 0.48; 95%CI 0.37, 0.63), rapid improvement within the first hour in pH (Weight Mean Difference 0.03; 95%CI 0.02, 0.04), PaCO(2) (WMD -0.40 kPa; 95%CI -0.78, -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26, -1.89). In addition, complications associated with treatment (RR 0.38; 95%CI 0.24, 0.60) and length of hospital stay (WMD -3.24 days; 95%CI -4.42, -2.06) was also reduced in the NPPV group. REVIEWER'S CONCLUSIONS: Data from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.

Adult↗

PubMed2004

Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD. SEARCH STRATEGY: An initial search was performed using the Cochrane Airways Group trials register and other relevant electronic databases. An updated search was conducted in September 2003 and another in April 2004. SELECTION CRITERIA: Randomised controlled trials comparing NPPV plus usual medical care (UMC) versus UMC alone were selected. Trials needed to recruit adult patients admitted to hospital with respiratory failure due to an exacerbation of COPD and with PaCO2 > 6 kPa (45 mmHg). DATA COLLECTION AND ANALYSIS: Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted the data. MAIN RESULTS: Fourteen studies were included in the review. NPPV resulted in decreased mortality (Relative Risk 0.52; 95%CI 0.35 to 0.76), decreased need for intubation (RR 0.41; 95%CI 0.33 to 0.53), reduction in treatment failure (RR 0.48; 95%CI 0.37 to 0.63), rapid improvement within the first hour in pH (Weight Mean Difference 0.03; 95%CI 0.02 to 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78 to -0.03) and respiratory rate (WMD -3.08 bpm; 95%CI -4.26 to -1.89). In addition, complications associated with treatment (RR 0.38; 95%CI 0.24 to 0.60) and length of hospital stay (WMD -3.24 days; 95%CI -4.42 to -2.06) was also reduced in the NPPV group. REVIEWERS' CONCLUSIONS: Data from good quality randomised controlled trials show benefit of NPPV as first line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.

Adult↗

PubMed2000

Meeting the need for educational standards in the practice of telemedicine and telehealth.

The first telemedicine standard to be developed, documented and adopted widely was the radiology standard, which includes technical and image transmission standards as well as requirements and qualifications needed for teleradiology practice. But many other health professionals engaged either full time or part time in telemedicine and telehealth--for example, telepsychiatry, telepathology, teletriage and tele-ophthalmology--also need and use special skills and knowledge. At present, they acquire these skills on the job and their skills may not be recognized. There should be performance standards and telepractice guidelines for professionals operating in the fields of telemedicine and telehealth. Furthermore, there is a case for the development and implementation of education and training standards, enabling professionals who practise in the field to obtain suitable skills, knowledge and recognition for telepractice.

Canada↗

PubMed1999

Towards a methodology for developing and implementing best practices in telehealth and telemedicine.

One objective of the growing telehealth and telemedicine literature base is to inform potential adopters and raise their awareness through pilot projects. However, pilot studies often fail to create sustainable solutions because certain conditions are needed for long term success: (1) matching needs to appropriate solutions: while needs assessment can identify needs, adopters must view, test, and experience potential solutions under a number of circumstances; (2) change and new technology: technological implementation brings both foreseen and unforeseen changes, difficult to forecast, and pilot projects can create artificial expectations; (3) awareness of context: there has been a pervasive tendency to treat telemedicine or telehealth as separate from the context of health care delivery, but telemedicine is only a communication and information tool, and should not be considered as separate from other health care delivery activities; (4) availability of long term funding; while loans, government grants and private sector partnering can bridge gaps temporarily, sustainable solutions require that savings from existing systems can be applied to pay for telehealth and telemedicine installations. This paper makes a case for adopting best practices by proposing that a data base of case studies documenting best practices and success factors be developed and made widely available.

Humans↗

PubMed1998

Molecular characterization of NOS in a mollusc: expression in a giant modulatory neuron.

Here we report on the molecular characterization of the first molluscan NOS in the CNS of the pond snail Lymnaea stagnalis. This Lymnaea NOS (Lym-nNOS) which is expressed preferentially in the CNS is most similar to mammalian neuronal NOS but contains tandem repeats of a seven amino acid motif not found in any other known NOS. We have localized Lym-nNOS to the serotonergic cerebral giant cells (CGCs) which modulate synaptic transmission within a neural network that generates feeding behavior. Our results suggest that the CGCs employ both NO and serotonin in the modulation of the central neural network underlying feeding.

Amino Acid Sequence↗

PubMed1998

Telemedicine and telehealth in Canada: forty years of change in the use of information and communications technologies in a publicly administered health care system.

The Canadian climate and geography are particularly well suited to the adoption of communications technologies for long-distance medical care and education. Canada has a long history of use of telemedicine applications, and in recent years, the number and variety of telehealth activities in Canada have increased dramatically. Using information gathered for a competitive framework study of the telehealth industry in Canada, this article documents these changes. The trends observed have been encouraged by the development of provincial and national infrastructure for the health information highway, changes in the health care system, increased technological capacity and speed, and government intervention and assistance. The pace of growth is apparent in the increases in the number of projects, the number of companies offering telehealth products and services, the adoption by public organizations of telehealth technologies for a wider range of applications, and the increasing amount of research being undertaken. The article concludes with comments on the role of government intervention in fostering these developments.

Canada↗

PubMed1984