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PubMed2002

Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

In general, randomized controlled studies concerning return to work have failed to demonstrate significant treatment effects for long-lasting musculoskeletal pain, and most treatments examined have not been economically beneficial. Individuals (n=654) sick-listed for at least 8 weeks with musculoskeletal pain, selected from the Norwegian mandatory sickness insurance system and volunteering to participate, were categorized into three groups differing in a prognosis score (good, medium, poor) for return to work, based on a brief, standardized screening of psychological and physiotherapy findings. They were then randomly assigned to three outpatient treatments with three different levels of intensity (ordinary treatment, light multidisciplinary, and extensive multidisciplinary treatment). The evaluation was based on 14 months follow-up data on return to work collected from social security records. The patients with good prognosis for return to work do equally well with ordinary treatment as with the two more intensive treatments. The patients with medium prognosis benefit equally from the two multidisciplinary treatments. The patients with poor prognosis receiving extensive multidisciplinary treatment returned to work at a higher rate than patients with poor prognosis receiving ordinary treatment, 55 vs. 37% (P<0.05) at 14 months. Multidisciplinary treatment is effective concerning return to work, when given to patients who are most likely to benefit from that treatment. Measures of pain or quality of life are not included in this study. The cost-benefit analysis of the economic returns of the light multidisciplinary and the extensive multidisciplinary treatment programs yields a positive net present social value of the treatment. A simple, standardized, screening instrument including only psychological and physiotherapeutic observations may be a useful clinical tool for allocating patients with musculoskeletal pain to the right level of treatment.

Adult↗

PubMed2005

Evidence-based practice in laparoscopic surgery: perioperative care.

Best practices for reducing risks of postoperative infection, venous thromboembolism, and nausea and vomiting in patients undergoing laparoscopic surgery are uncertain. As a result, perioperative care varies widely. We reviewed evidence from randomized clinical trials on the effectiveness of interventions for postoperative infection, venous thromboembolism, and nausea and vomiting Data sources were the Cochrane Central Register of Clinical Trials, reference lists of published trials, and randomized clinical trials published in English since 1990. Trials were also limited to those focused on patients undergoing laparoscopic surgery. Data from 98 randomized clinical trials were included in the final analysis. Routine antibiotic use in laparoscopic cholecystectomy, and possibly other clean procedures not involving placement of prostheses, is likely unnecessary. Similarly, venous thromboembolism prophylaxis is probably unnecessary for low-risk patients undergoing brief procedures. Of a wide variety of methods for reducing postoperative nausea and vomiting, serotonin receptor antagonists appear the most effective and should be considered for routine prophylaxis.

Humans↗

PubMed1997

Mesalamine in the maintenance treatment of Crohn's disease: a meta-analysis adjusted for confounding variables.

BACKGROUND & AIMS: The benefit of mesalamine for maintenance of remission in Crohn's disease is controversial. The aim of this study was to assess the effectiveness of mesalamine in maintaining remission of quiescent Crohn's disease. METHODS: Pertinent randomized clinical trials were selected using MEDLINE (1986-1997) database, reference lists from published articles or reviews. Fifteen randomized, controlled trials of mesalamine maintenance therapy involving a total of 2097 patients were selected. The crude rates of patients with symptomatic relapse in treated and control groups were extracted according to the intention-to-treat method. RESULTS: Therapy with mesalamine significantly reduced the risk of symptomatic relapse (pooled risk difference, -6.3%; 95% confidence interval, -10.4% to -2.1%). The pooled risk difference was significant in the postsurgical setting (-13.1%; 95% confidence interval, -21.8% to -4.5%) but not in the medical setting (-4.7%; 95% confidence interval, -9.6% to 2.8%). Multivariate model predicts that the probability of symptomatic relapse significantly decreases with mesalamine treatment, by increasing proportion of patients with ileal disease, with prolonged disease duration, and with surgically induced remission. CONCLUSIONS: Mesalamine may be recommended for maintaining remission of quiescent Crohn's disease. The benefit is mainly observed in the postsurgical setting, in patients with ileitis and with prolonged disease duration.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2005

Dissemination of 'patient-oriented evidence that matters' on the Internet: the case of Type 2 diabetes treatment.

AIMS: To evaluate the dissemination of patient-oriented evidence that matters (POEMs) derived from the UK Prospective Diabetes Study (UKPDS) through health information websites. METHODS: Google and Altavista search engines were used to generate a list of websites about Type 2 diabetes treatments. We evaluated a random sample of 50 websites from each list, plus the first 10 websites displayed on each search engine looking for the presence of POEMs about diabetes treatment derived from the UKPDS. Websites were also ranked using the DISCERN instrument. RESULTS: The final sample consisted of 66 websites. The most frequently stated item was that tight blood pressure decreased complications and/or mortality (55.5%). The effects of metformin on morbidity and/or mortality in overweight patients and the greater effect of control of blood pressure rather than blood glucose control on complications were stated in 18.2 and 16.7% of cases, whereas the lack of effect of tight blood glucose control on premature mortality and of insulin or sulphonylureas on aggregate micro- or macrovascular outcomes in overweight patients were stated in one case each (1.5%). The lack of effect of tight blood glucose control on quality of life was not stated in any website. POEMs were more frequently present in websites rated high with the DISCERN instrument, websites with the Health-on-the-Net seal and non-commercial websites. CONCLUSIONS: The dissemination of POEMs through the Internet is poor. If patients are to be involved in decision-making processes, efforts should be made to update the Internet contents to meet this challenge.

Databases, Factual↗

PubMed2005

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics.

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.

Academic Medical Centers↗

PubMed2004

Opinions of UK specialists about terminology, diagnosis, and treatment of atypical facial pain: a survey.

There are few robust, evidence-based data about what constitutes the diagnosis of atypical facial pain and how it is best treated. We therefore aimed to find out the current opinion of those on specialist lists in the United Kingdom (UK) on whether they use the term atypical facial pain, how they reach their diagnosis, and what treatment they offer. We sent out questionnaires to 240 specialists randomly selected from the UK lists of those most likely to deal with atypical facial pain (oral and maxillofacial surgeons, oral medical specialists, ear nose and throat surgeons, anaesthetists, psychiatrists and neurologists). We divided the replies according to whether the specialists were medically or dentally based. Of the 209 valid questionnaires, 143 were returned (a response rate of 68%); 127 of the 143 used the term atypical facial pain, the others used various other terms. The two groups used significantly different criteria, mainly to exclude other conditions to achieve a diagnosis. About half used haematological tests and most used radiographic investigations routinely, and there were no significant differences among the specialities. No unified pattern of referral between different units was found. Treatment was mainly by antidepressant and anticonvulsant drugs, and counselling.

Attitude of Health Personnel↗

PubMed1999

Authoritative knowledge, evidence-based medicine, and behavioral pediatrics.

Evidence-based medicine is the conscientious and judicious use of current best knowledge in making decisions about the care of individual patients, often from well-designed, randomized, controlled trials. Authoritative medicine is the traditional approach to learning and practicing medicine, but no one authority has comprehensive scientific knowledge. Archie Cochrane proposed that every medical specialty should compile a list of all of the randomized, controlled trials within its field to be available for those who wish to know what treatments are effective. This was done first for obstetrics by a group collecting and critically analyzing all of the randomized trials and then indicating procedures every mother should have and those that no mother should have. Support during labor was used as an example. Similar groups are now active in almost all specialties, with information available on the Internet in the Cochrane Database of Systematic Reviews. Developmental-behavioral pediatrics should be part of this movement to evidence-based medicine.

Adolescent↗

PubMed1998

[Differences between listed and unlisted telephone subscribers among telephone survey respondents].

The number of telephone surveys conducted has increased in Japan, with the telephone directory often used for sampling respondents in telephone surveys. As some subscribers request that their numbers not be listed, they are excluded. The Random Digit Dialing (RDD) survey method, however, not only makes possible smooth data collection, but also random sampling of all subscribers in telephone surveys. The authors conducted a telephone survey in Tokyo using the RDD method to investigate any differences in behavior and demographic or social attributes between listed and unlisted subscribers. These attributes included gender, age, family size, job, and residential area. The findings were as follows: 1) The listing rate in telephone directories was 65.8% among respondents. 2) Old age, large family size and certain residential areas correlated with higher listing rates. 3) Nevertheless, the relationship between listing in the telephone directory and residential area remains somewhat unclear due to the confounding attributes of age and family size. 4) Using Hayashi's second method of quantification, age, family size and occupation correlated with listing frequency. 5) There were also significant differences between listed and unlisted subscribers on questions of health maintenance and lifestyle.

Adult↗

PubMed2000

Intravenous immunoglobulin for suspected or subsequently proven infection in neonates.

BACKGROUND: Congenital and nosocomial infections are important causes of neonatal morbidity and mortality. Maternal transport of immunoglobulins to the fetus mainly occurs after 32 weeks gestation and endogenous synthesis does not begin until several months after birth. Administration of intravenous immunoglobulin provides IgG that can bind to cell surface receptors, provide opsonic activity, activate complement, promote antibody dependent cytotoxicity, and improve neutrophilic chemoluminescence. Theoretically infectious morbidity and morbidity could be reduced by the administration of intravenous immunoglobulin. OBJECTIVES: To assess the effectiveness of intravenous immunoglobulin (IVIG) to reduce mortality/morbidity caused by suspected infection in newborn infants. In secondary analyses to assess the effectiveness of IVIG to reduce mortality/morbidity in those neonates who entered into the studies with suspected infection and who later were confirmed as being infected. SEARCH STRATEGY: Medline, Embase, and Reference Update Databases were searched in November 1997, and the Cochrane Library in July 1998 using the following keywords: immunoglobulin and infant-newborn, and random allocation, or controlled trial, or randomized controlled trial (RCT). The reference lists of identified RCTs and meta-analyses, personal files and Science Citation Index were also searched. No language restrictions were applied. Unpublished data were requested from authors and information has been obtained from one author to date. SELECTION CRITERIA: The criteria used to select studies for inclusion were: 1) DESIGN: RCT (including quasi-randomized trials) 2) Newborn infants (< 28 days old) 3) INTERVENTION: IVIG for treatment of suspected (and in some infants subsequently proved) bacterial/fungal infection compared to placebo or no intervention. Suspected infection was defined as clinical symptoms and signs consistent with infection without isolation of causative organism. Proved infection was defined as: clinical symptoms and signs consistent with infection in association with isolation of causative organism from either blood culture, cerebrospinal fluid culture, urine culture (urine obtained by suprapubic tap) or a normally sterile site (e.g., liver, spleen, meninges, lung) at autopsy. 4) At least one of the following outcomes was reported: mortality during initial hospital stay; length of hospital stay; side effects; psychomotor development/growth at follow up. DATA COLLECTION AND ANALYSIS: Two reviewers independently abstracted information for the outcomes of interest and one researcher (AO) checked for any discrepancies and pooled the results. Relative risk (RR) and Risk Difference (RD) with 95% confidence intervals (CI) using the fixed effects model are reported for dichotomous outcomes and weighted mean difference (WMD) for continuous data. NNT was calculated for outcomes that showed a statistically significant reduction in RD. Data from quasi-randomized trials were excluded in sensitivity analyses. MAIN RESULTS: Study quality was generally poor. Four of 7 identified studies (n = 208), reported on the outcomes of all randomized patients with clinically suspected infection. Mortality was reduced [RR 0.52 (95% CI; 0.28, 0.98), RD -0.102 (95% CI; -0.005, -0.199, NNT 10 (95% CI; 5, 200]. When, in a sensitivity analysis (n = 126), the results from a quasi-randomized trial (n = 82) were excluded, RR and RD remained similar, [RR 0.53 (95% CI; 0.25, 1.15), RD -0.106 (-0.232, 0.021)] but statistical significance was lost. Treatment with IVIG (six trials, n = 234) in cases of subsequently proved infection did not result in a statistically significant reduction in mortality [RR 0.62 (95% CI; 0.34, 1.12, RD -0.074 (95% CI; -0.163, 0. 014)]. Excluding in a sensitivity analysis (n = 199) a quasi-randomized trial (n = 35) changed the results slightly [RR 0. 68 (95% CI; 0.36, 1.29), RD -0.059 (-0.152, 0.035)]. There was no statistically significant between-study

Humans↗

PubMed1998

Visual function among corneal disease patients waiting for penetrating keratoplasty in British Columbia.

PURPOSE: We sought to test the applicability of a well-documented visual function assessment (VF-14) in corneal disease patients wait-listed for penetrating keratoplasty to determine if it would be a valuable addition to a priority scheme. METHODS: A systematic random sample of patients wait-listed for penetrating keratoplasty in British Columbia was selected and administered the VF-14. RESULTS: The mean VF-14 score was 67.2; it was correlated with best corrected vision. Immigrants had lower VF-14 scores and they considered fewer of the questions applicable to them. There was a correlation between the number of questions considered applicable and the VF-14 score. CONCLUSIONS: As currently constituted the VF-14 is probably not a useful tool in a multi-cultural population in North America. We propose revisions to the visual function assessment and suggest its inclusion in a priority scheme for penetrating keratoplasty that also includes pain and other clinical indices.

British Columbia↗

PubMed2001

Dyspnoea and quality of life in older people at home.

OBJECTIVES: To determine the prevalence of dyspnoea in older people at home, measure its impact on function and quality of life, and identify associated cardio-respiratory diseases. DESIGN: Cross-sectional population-based study. METHODS: We sent a modified Medical Research Council (MRC) dyspnoea questionnaire to identify breathlessness in 1404 randomly selected subjects from general practitioner lists of 5002 subjects aged 70 years and over living at home. We visited a further random sample of 500 of these subjects at home and at a study centre. SETTING: Community-based study in South Wales. MAIN OUTCOME MEASURES: Prevalence of dyspnoea (MRC grades 3-5) and its effect on psychological and functional status, and quality of life as measured by Hospital Anxiety and Depression, Nottingham Extended Activities of Daily Living and SF-36 questionnaires. RESULTS: The prevalence of dyspnoea as defined was 32.3% (95% confidence intervals: 30.3, 34.3). Breathless subjects had poorer functional status than non-breathless subjects. They also had poorer physical and mental health and were more likely to be anxious and depressed. The prevalence of left ventricular systolic dysfunction, reversible airways disease and obesity were all higher in those with dyspnoea. CONCLUSIONS: Dyspnoea is common in older people. Given its profound adverse effect on people's lives, dyspnoea is an important public health issue.

Aged↗

PubMed2003

Adjuvant corticosteroids for tuberculous pericarditis: promising, but not proven.

BACKGROUND: There is controversy regarding the effectiveness of corticosteroids in tuberculous pericarditis, particularly in patients who are immunocompromised by HIV. AIM: To determine the effectiveness of adjuvant corticosteroids in tuberculous pericarditis. DESIGN: Systematic review of randomized controlled trials. METHODS: We searched the Cochrane Infectious Diseases Group trials register (June 2002), the Cochrane Controlled Trials Register (Issue 2, 2002), MEDLINE (January 1966 to March 2003), EMBASE (1980 to May 2002), and the reference lists of existing reviews, for randomized and quasi-randomized controlled trials of adjuvant corticosteroids in the treatment of suspected tuberculous pericarditis. We also contacted organizations and individuals working in the field. Two reviewers independently assessed trial quality and extracted data. We used meta-analysis with a fixed effects model to calculate the summary statistics, provided there was no statistically significant heterogeneity, and expressed results as relative risk. RESULTS: Four trials with a total of 469 participants met our criteria. Three (total n = 411) tested adjuvant steroids in participants with suspected tuberculous pericarditis in the pre-HIV era. Fewer participants died in the intervention group, but the potentially large reduction in mortality was not statistically significant (relative risk RR 0.65, 95%CI 0.36-1.16, n = 350; p = 0.14). One trial with 58 patients that enrolled HIV-positive individuals also showed a promising but non-significant trend on mortality (RR 0.50, 95%CI 0.19-1.28; p = 0.15). There was no significant beneficial effect of steroids on re-accumulation of pericardial effusion or progression to constrictive pericarditis. Patients with pericardial effusion were significantly more likely to be alive with no functional impairment at 2 years following treatment. However, the effect was not sustained in a sensitivity analysis that included patients who were lost to follow-up. DISCUSSION: Steroids could have large beneficial effects on mortality and morbidity in tuberculous pericarditis, but published trials are too small to be conclusive. Large placebo-controlled trials are required, and should include sufficient numbers of HIV-positive and HIV-negative participants, and an adequate adjuvant steroid dose.

Adrenal Cortex Hormones↗

PubMed1991

Using immediate recall to assess language proficiency in deaf students.

We used an immediate recall paradigm to study the effects of list organization and semantic and grammatical features of printed stimuli on working memory capacity in deaf students with differing English language abilities. Thirty lists of five organizational types (random words, semantically related words, semantically paired words, scrambled sentences, and grammatical sentences) were presented to two groups of deaf students who differed in their proficiency in the English language. The students were required to recall the lists in writing. The results indicate that, overall, the students with higher levels of English language proficiency recalled significantly more than those with lower levels. Additionally, semantic and syntactic organization of the lists had different effects on the two groups of students. Semantic pairing aided the low-level group significantly more than the high-level group, whereas the syntactic organization of the grammatical sentences aided the high-level group significantly more. Implications for assessing language ability in deaf students are discussed.

Adolescent↗

PubMed2004

The association between 3-hydroxy-3-methylglutaryl conenzyme A inhibitor use and breast carcinoma risk among postmenopausal women: a case-control study.

BACKGROUND: Statin use has increased dramatically in the U.S. in the past decade. Animal and mechanistic studies suggested that statins may have an inhibitory effect on cancer proliferation, including breast carcinoma. However, statins have been found to be carcinogenic in rodents and one clinical trial found an excess of breast carcinoma cases in the treatment group. METHODS: The current study assessed whether the use of statins altered the risk of breast carcinoma in older women. The population-based, case-control study comprised female residents from three western Washington State counties. Cases included 975 women identified from the Cancer Surveillance System who were diagnosed with primary invasive breast carcinoma between 1997-1999, whose names appeared on a list of Social Security recipients provided by the Centers for Medicare and Medicaid Services. The cases were ages 65-79 years at the time of diagnosis. The comparison group was comprised of 1007 women without breast carcinoma who were randomly selected from the same list of Social Security recipients. Information pertaining to statin use, medical history, and health behaviors was ascertained through an in-person interview. RESULTS: Compared with nonusers, women who were currently using statins or had ever used statins were not found to be at an increased risk for breast carcinoma (odds ratios [OR] = 0.9; 95% confidence interval [95% CI], 0.7-1.2). There was some indication that long-term statin use (> 5 years) was related to a slight decrease in breast carcinoma risk (OR = 0.7; 95% CI, 0.4-1.0). CONCLUSIONS: The results of the current study provided some degree of reassurance to the increasing numbers of women using statins that such use is not associated with an increased risk of breast carcinoma. Although the data gave some support to a reduced risk of breast carcinoma among long-term users of statins, further research is needed to confirm this association.

Aged↗

PubMed2006

Global gist extraction in children and adults.

The DRM paradigm was used to examine the role of global gist extraction in producing false memories in children and adults. First-graders, third-graders, and adults watched a videotape of a woman reading seven DRM lists, and then took a recognition memory test. Blocked (vs random) presentation and instructions to attend to the theme of lists were manipulated to enhance gist processing. In the first experiment, blocked presentation increased false recognition relative to random presentation in adults but not in first-graders or third-graders. In the second experiment, instructions to attend to list themes increased false recognition in third-graders and not in adults or first-graders. The results suggest a developmental pattern in which children become more adept at global gist extraction as they get older. These results are consistent with fuzzy trace theory's prediction of better gist processing as children grow older.

Adolescent↗

PubMed2006

OrderedList--a bioconductor package for detecting similarity in ordered gene lists.

UNLABELLED: OrderedList is a Bioconductor compliant package for meta-analysis based on ordered gene lists like those resulting from differential gene expression analysis. Our package quantifies the similarity between gene lists. The significance of the similarity score is estimated from random scores computed on perturbed data. OrderedList illustrates list similarity in intuitive plots and determines the score-driving genes for further analysis. AVAILABILITY: http://www.bioconductor.org CONTACT: claudio.lottaz@molgen.mpg.de SUPPLEMENTARY INFORMATION: Please visit our webpage on http://compdiag.molgen.mpg.de/software.

Algorithms↗

PubMed2006

Psychological well-being and relationship outcomes in a randomized study of family-led education.

CONTEXT: Family members of adults with mental illness often experience emotional distress and strained relationships. OBJECTIVE: To test the effectiveness of a family-led educational intervention, the Journey of Hope, in improving participants' psychological well-being and relationships with their ill relatives. DESIGN AND SETTING: A randomized controlled trial using a waiting list design was conducted in the community in 3 southeastern Louisiana cities. PARTICIPANTS: A total of 462 family members of adults with mental illness participated in the study, with 231 randomly assigned to immediate receipt of the Journey of Hope course and 231 assigned to a 9-month course waiting list. Intervention The Journey of Hope intervention consisted of 8 modules of education on the etiology and treatment of mental illness, problem-solving and communication skills training, and family support. MAIN OUTCOME MEASURES: Participants' psychological well-being and relationships with their ill relatives were assessed at study enrollment, 3 months after enrollment (at course termination), and 8 months after enrollment (6 months after course termination). Mixed-effects random regression analysis was used to predict the likelihood of decreased depressive symptoms, increased vitality, and overall mental health, and improved relationship ratings. RESULTS: Intervention group participants reported fewer depressive symptoms, greater emotional role functioning and vitality, and fewer negative views of their relationships with their ill relatives compared with control group participants. These improved outcomes were maintained over time and were significant (P<.05 for all) even when controlling for participant demographic and relative clinical characteristics. CONCLUSION: Results show that family-led educational interventions are effective in improving participants' psychological well-being and views of their relationships with ill relatives.

Adult↗

PubMed2000

Defining the content for the objective structured clinical examination component of the professional and linguistic assessments board examination: development of a blueprint.

INTRODUCTION: We describe the steps taken to develop an appropriate list of 'clinical problems' used to define the content of the objective structured clinical examination (OSCE) component of the Professional and Linguistic Assessments Board (PLAB) examination. METHOD: A blueprint and list of 255 clinical problems was compiled by reviewing PLAB questions, published curricula of the UK Royal Colleges and other sources such as the General Medical Council's own guidelines. This list was sent to a random sample of 251 successful PLAB candidates who were asked to rate the clinical problems using a scale of 'seen frequently/seldom/never' and to 120 members of the accident and emergency (A&E) specialists' association who were asked to identify 'important' tasks. The list was further validated using activity data obtained for consecutive A&E attendances (934) and admissions (6130) at three hospitals. RESULTS: After two mailings, 131/251 (52%) former PLAB candidates and 89/120 (74%) A&E specialists replied. All of the 255 clinical problems were seen by some former candidates and were felt to be important by some A&E specialists. Of the 255 problems, 40 were neither rated as important nor as seen frequently/seldom by over 50% of respondents. The 255 clinical problems covered a mean 94% consecutive A&E attendances and 97.6% reasons for hospital admission. The correlation between clinical problems that were frequently encountered and those felt to be important was rho=0.38 (P<0.01). CONCLUSION: The clinical problems appear to be appropriate for defining the content of the PLAB OSCE. We suggest that our problem list is useful in that all the problems are seen by some senior house officers, are felt to be important by some A&E specialists and cover greater than or equal to 94% of the conditions for which patients both attend and are admitted from casualty. The correlation between clinical task importance and the frequency that they were seen was only moderate, partly reflecting the relative seriousness of some uncommon medical conditions, which should not be missed on clinical assessment. The content of the OSCE component of the PLAB examination is being reviewed in the light of the findings of this study. The limitations of the study are discussed.

Clinical Competence↗