Medicinal use of potato-derived products: a systematic review

In the traditional medicine of Europe, raw potatoes are used for gastrointestinal disorders, and topical potato preparations as a hot pack for pain or for softening furuncles. The aim of this study was to review the literature and summarize the data on the medicinal use of potato-derived products. Several databases and other sources were searched to identify clinical trials investigating potato-derived preparations. The trials were analysed for quality. Five trials were identified; two open uncontrolled studies, two open controlled studies and one double-blind study. These results stimulate further investigation of oral potato juice concentrate in patients with dyspeptic complaints, of potato proteinase inhibitor II for weight reduction, and of topical potato proteins for preventing protease-induced perianal dermatitis. We recommend that future studies have a confirmatory design.

A systematic review on the effectiveness of willow bark for musculoskeletal pain

Since ancient times preparations from Salix species have been used to alleviate pain. The aim of this study was to update the evidence of the effectiveness of willow bark products in the treatment of musculoskeletal pain. OVID(MEDLINE), PUBMED, Silverplatter, and CENTRAL and manual searches were used to identify clinical trials investigating Salix preparations. Authors SC and JEV extracted the data independently and discussed disagreements. Seven manuscripts were identified, reporting four trials with confirmatory and four with exploratory study designs. Three manuscripts presented the same trial data: repetitious reports were excluded. One confirmatory and two exploratory studies indicate a dose-dependent analgesic effect not inferior to rofecoxib in patients with low back pain. In one exploratory and one confirmatory study conflicting results were achieved in participants with osteoarthritis. No significant effect was seen in a confirmatory study in patients with rheumatoid arthritis, but this study was grossly underpowered. All studies investigated ethanolic extracts with daily doses up to 240 mg salicin over periods of up to six weeks. Minor adverse events occurred during treatment. The review provides moderate evidence of effectiveness for the use of ethanolic willow bark extract in low back pain. Further studies are required to find out if treatment of osteoarthritis and rheumatoid arthritis requires extract with higher doses than 240 mg salicin per day.

Cost-effectiveness of surgical interventions for BRCA gene mutation carriers: impact of delaying decision-making

Abstract #503

Purpose
 Women who carry a BRCA1 or BRCA2 genetic mutation are at significantly increased risk of breast and ovarian cancer. Interventions to reduce the risk of these cancers available these women include bilateral prophylactic mastectomy (PM) and oophorectomy (PO), or both (PMPO). However, women are often reluctant to choose these options, and prefer to delay these surgeries for childbearing or other reasons. We sought to identify the effectiveness and cost-effectiveness of these interventions and to evaluate the potential consequences of delaying prophylactic surgery in terms of risk of cancer diagnosis and life expectancy.
 Methods
 A Markov model was developed to compare the effectiveness and cost-effectiveness of prophylactic surgery in cohorts of women with the BRCA1 and BRCA2 mutations without prior breast or ovarian cancer. Multiple strategies were explored to evaluate the benefit of these interventions at various ages. Costs were estimated using Medicare reimbursement rates and secondary sources. Other model variables were estimated from the literature. Effectiveness was measured in life-years gained and quality-adjusted life-years gained in addition to breast and ovarian cancers diagnosed.
 Results
 All surgeries significantly prolong survival at all ages explored (age 30 to 45), although much more so in younger women and in BRCA1 compared to BRCA2 carriers. BRCA1 carriers at age 30 have an increased life expectancy of 4, 8, and 13 years for PM, PO, and PMPO, whereas BRCA2 carriers have an increased life expectancy of 3, 3, and 6 years respectively, vs. 2, 4, 6 years (BRCA1) and 2, 2, 4 years (BRCA2) at age 45. BRCA1 carriers who delay prophylactic surgery are projected to have a 6.4% chance of a cancer diagnosis before age 35 vs. 35% chance before age 45. BRCA2 carriers who delay surgery are projected to have a 2.6% vs. 12.1% chance of cancer diagnosis before age 35 and 45 respectively. Compared to surveillance, all options have incremental cost effectiveness ratios (ICER) less than $50,000 per quality adjusted life year gained in BRCA1 carries. However, some of these strategies are not considered cost-effective in BRCA2 carriers.
 Conclusions
 Surgical prophylactic interventions for known BRCA mutation carriers are very effective and cost-effective, although more so in younger women and in BRCA1 carriers as compared to BRCA2 carriers. These interventions are life-saving even when delayed; however, for individuals who have high disutility for prophylactic surgery, these options may reduce quality-adjusted life expectancy regardless of when the surgery is performed. Patients need to be aware of the short-term cancer risk from delaying prophylactic intervention to ensure informed trade-offs. Selection of individuals who perceive low harm or anticipate minimal adjustment to the prophylactic interventions will ensure cost-effective use of these surgical interventions.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 503.

The influence of climate on Glossy Black-cockatoo reproduction

Glossy Black-cockatoos Calyptorhynchus lathami are dietary specialists, feeding almost exclusively on the seeds of Allocasuarina and Casuarina species. Their specialized diet makes them vulnerable to alterations in their food supply, and populations inhabiting variable environments are good candidates for identifying reproductive strategies that match output to the available food supply. I studied reproduction in a population of Glossy Black-cockatoos in central New South Wales, a region where rainfall varies substantially between years and which is subject to periodic drought. Seed production in the principal Glossy Black-cockatoo feed species in the region tracks rainfall, and as a consequence, the Glossy Black-cockatoo food resource fluctuates between years. I monitored nest success and population structure between 1997 and 2004, a period that included wet and dry years. There was a strong relationship between cockatoo productivity and rainfall in the preceding year. The principal determinant of annual productivity was the number of pairs attempting to breed. Increased aridity as a result of climate change will have negative consequences for inland populations of Glossy Black-cockatoos. Careful management of their habitat will be required if Glossy Black-cockatoo populations are to persist in the long term.

The value of proteomics for the diagnosis of a platelet-related bleeding disorder

Familial bleeding problems are frequently difficult to diagnose because currently used clinical tests cannot identify intracellular molecular defects of platelets. Using platelet proteomics, a comprehensive analytical tool, we diagnosed a family with severe bleeding problems of unknown origin with Quebec Platelet Disorder. Prior to proteomic analysis, we determined platelet counts, presence of glycoprotein (GP) Ib and GPIIb/IIIa, platelet aggregation, dense granule content and release, plasma levels of fibrinogen, Factor XIII and fibrin degradation products in four family members. Abnormalities were detected in platelet aggregation studies, which revealed variably reduced responses to ADP, collagen and epinephrine with concomitantly decreased ATP/serotonin secretion. In addition, D-dimer levels were significantly elevated 72 hours after in vitro thrombin stimulation of platelet-rich plasma. Together with the autosomal dominant inheritance and the delayed onset of bleeding in two of the four patients these results did not support any known platelet disorder. Therefore, the proteome of platelet lysates separated by one-dimensional SDS-PAGE was analysed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Platelet proteomics showed reduced amounts of alpha-granule proteins multimerin, fibrinogen and thrombospondin-1 in patient compared to control samples suggestive of Quebec Platelet Disorder. The diagnosis of Quebec Platelet Disorder was confirmed by urokinase-specific Western blots. Urokinase causes the degradation of alpha-granule proteins in this disorder. Diagnosis of rare bleeding disorders has important implications for prophylactic and acute treatment of bleeding patients. This is the first report using proteomics to identify a familial platelet defect.

Overall impact of speed-related initiatives and factors on crash outcomes

From December 2000 until July 2002 a package of speed-related initiatives and factors took place in Victoria, Australia. The broad aim of this study was to evaluate the overall impact of the package on crash outcomes. Monthly crash counts and injury severity proportions were assessed using Poisson and logistic regression models respectively. The model measured the overall effect of the package after adjusting as far as possible for non-speed road safety initiatives and socio-economic factors. The speed-related package was associated with statistically significant estimated reductions in casualty crashes and suggested reductions in injury severity with trends towards increased reductions over time. From December 2000 until July 2002, three new speed enforcement initiatives were implemented in Victoria, Australia. These initiatives were introduced in stages and involved the following key components: More covert operations of mobile speed cameras, including flash-less operations; 50% increase in speed camera operating hours; and lowering of cameras' speed detection threshold. In addition, during the period 2001 to 2002, the 50 km/h General Urban Speed Limit (GUSL) was introduced (January 2001), there was an increase in speed-related advertising including the "Wipe Off 5" campaign, media announcements were made related to the above enforcement initiatives and there was a speeding penalty restructure. The above elements combine to make up a package of speed-related initiatives and factors. The package represents a broad, long term program by Victorian government agencies to reduce speed based on three linked strategies: more intensive Police enforcement of speed limits to deter potential offenders, i.e. the three new speed enforcement initiatives just described - supported by higher penalties; a reduction in the speed limit on local streets throughout Victoria from 60 km/h to 50 km/h; and provision of information using the mass media (television, radio and billboard) to reinforce the benefits of reducing low level speeding - the central message of "Wipe Off 5". These strategies were implemented across the entire state of Victoria with the intention of covering as many road users as possible. This study aimed to evaluate the overall effectiveness of the speed-related package. The study objectives were: to document the increased speed camera activity in each speed limit zone and in Melbourne compared with the rest of Victoria; to evaluate the overall effect on crash outcomes of the package; to account as far as possible for the effect on crash outcomes of non-speed road safety initiatives and socio-economic factors, which would otherwise influence the speed-related package evaluation; and to examine speed trends in Melbourne and on Victorian rural highways, especially the proportions of vehicles travelling at excessive speeds. This paper presents the results of the evaluation of the overall impact on crash outcomes associated with the speed-related package, after adjusting as far as possible for the effect of non-speed road safety initiatives and socio-economic factors. D'Elia, Newstead and Cameron (2007) document the study results in full.

An index for rating the total secondary safety of vehicles from real world crash data

This study proposes a total secondary safety index for light passenger vehicles that rates the relative performance of vehicles in protecting both their own occupants and other road users in the full range of real world crash circumstances. The index estimates the risk of death or serious injury to key road users in crashes involving light passenger vehicles across the full range of crash types. The proposed index has been estimated from real world crash data from Australasia and was able to identify vehicles that have superior or inferior total secondary safety characteristics compared with the average vehicle.

Superficial heat or cold for low back pain

BACKGROUND

Heat and cold are commonly utilised in the treatment of low-back pain by both health care professionals and people with low-back pain.

OBJECTIVES

To assess the effects of superficial heat and cold therapy for low-back pain in adults.

SEARCH STRATEGY

We searched the Cochrane Back Review Group Specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005) and other relevant databases.

SELECTION CRITERIA

We included randomised controlled trials and non-randomised controlled trials that examined superficial heat or cold therapies in people with low-back pain.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality and extracted data, using the criteria recommended by the Cochrane Back Review Group.

MAIN RESULTS

Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days (weighted mean difference (WMD) 1.06, 95% confidence interval (CI) 0.68 to 1.45, scale range 0 to 5) compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application (WMD -32.20, 95%CI -38.69 to -25.71, scale range 0 to 100). One trial of 100 participants with a mix of acute and sub-acute low-back pain examined the additional effects of adding exercise to heat wrap, and found that it reduced pain after seven days. There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain.

AUTHORS' CONCLUSIONS

The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomised controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Snookered! Facial infection secondary to occult foreign body

A case is presented of a man suffering from a severe purulent temporofacial infection that was secondary to an occult foreign body. The patient had been impaled on a 13 cm section of snooker cue and was entirely unaware of its presence despite the size. The management of this case is presented and discussed.

Synchronous reconstruction of the exenterated orbit with a pericranial flap, skin graft and osseointegrated implants

Reconstruction of the exenterated orbit remains a surgical challenge. Here, the authors present a case in which orbital exenteration was performed for an extensive, infiltrating medial canthal basal cell carcinoma; the resulting defect was reconstructed with osseointegrated implants and a pericranial flap onto which a split thickness skin graft was placed. The second stage of the aesthetic rehabilitation of this patient (placement of the transcutaneous abutments) was completed under local anaesthetic 16 weeks later. Subsequently, the patient was fitted with an oculoplastic prosthesis four weeks later. The above technique accelerates the prosthetic rehabilitation of the patient by performing the primary reconstructive procedures simultaneously with the exenteration and by removing the need for secondary surgical procedures under general anaesthetics. The whole process from orbital exenteration to the fitting of an ocular prosthesis was completed in just five months.

The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian Rules football players

The purpose of this study was to use MRI to classify acute grade one hamstring muscle strains in Australian Rules footballers to determine if it was accurate in predicting the recovery time for each injury and also able to predict those that would recur within the same season. A prospective study was performed over five years at a professional Australian Football League club. Thirty-one acute grade one hamstring injuries underwent MRI examination within 24-72 hours following the injury. Each injury underwent the same rehabilitation programme. The rehabilitation interval (RI) was the time in days for the player to resume full team training. Fourteen (45%) of the injuries were normal on MRI. Seventeen (55%) were abnormal with a hyperintense T2 lesion on the axial fat suppressed views. The MRI negative group had a significantly faster RI (6.6 days) compared with the MRI positive group (20.2 days). Both the length and cross sectional area (CSA) of the MRI positive lesions were measured. The length of the lesion had a stronger correlation coefficient with the RI (0.84) than did the CSA (0.76). Six of the 17 MRI positive strains recurred with no correlation found between the lesion's length or CSA, or the RI. None of the 14 MRI negative injuries recurred. The study confirms that MRI can aid in the investigation of acute grade one hamstring muscle strains in predicting recovery time. However the size of the initial strain or the RI do not seem to be reliable indicators in predicting those strains that might recur.

Respite care for people with dementia and their carers

BACKGROUND

Caring for someone with dementia can be emotionally and physically demanding. Respite care is any intervention designed to give rest or relief to caregivers. It is not clear what positive and negative effects the provision of respite care may have on people with dementia and their caregivers.

OBJECTIVES

To assess the effects of respite care for people with dementia and their caregivers, in particular the effect of respite care on rates of institutionalization.

SEARCH STRATEGY

The trials were identified from a last updated search of the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 2 July 2003 using the terms respite* and "day care". This Register contains up to date records from all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Randomized controlled trials comparing respite care with a control intervention for people with dementia.

DATA COLLECTION AND ANALYSIS

Both reviewers carried out study selection independently and reached a consensus through discussion. Data was extracted by a single reviewer. The reviewers contacted all investigators for methodological details not reported in the text and for additional data.

MAIN RESULTS

Three trials were included in the review. They were different in many ways including intervention, duration and outcomes so pooling of data was not possible. Re-analysis of outcomes using data from the published studies found no significant effects of respite care on any variable.

REVIEWERS' CONCLUSIONS

Current evidence does not demonstrate any benefits or adverse effects from the use of respite care for people with dementia or their caregivers. These results should be treated with caution, however, as they may reflect the lack of high quality research in this area rather than an actual lack of benefit. Given the frequency with which respite care is advocated and provided, well-designed trials in this area are needed.

Valproic acid for agitation in dementia

BACKGROUND

Agitation affects up to 70% of older people with dementia. Valproic acid has been used for the past 10 years to control agitation in dementia, but no systematic review of the effectiveness of this drug has been published to date. The current study examines three randomized, placebo-controlled trials of the effect of valproic acid on older people with dementia who were agitated.

OBJECTIVES

To determine whether evidence supports the use of valproic acid in the treatment of agitation of people with dementia.

SEARCH STRATEGY

Trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 10 July 2003 using the terms ("agitat*" or "distur*" or "behavi*" or "aggress*") and "valproic" or "valproate" or "divalpro*." This Register contains articles from all major health care databases and many ongoing trials databases and is regularly updated. The reviewers contacted the authors of publications and drug companies manufacturing valproic acid for additional information.

SELECTION CRITERIA

Randomized, placebo-controlled trials with concealed allocation where agitation and dementia of participants were assessed

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from published trials. 2. Odds ratios of average differences were calculated. 3. Only "intention to treat" analyses were included. 4. Analysis compared participants treated with valproic acid with controls.

MAIN RESULTS

Meta-analysis of the pooled results of the included trials could not be performed because of the following problems. In Porsteinsson 2001, although the physicians having direct responsibility for patient care were blinded, a non-blinded physician, who had no direct contact with these physicians, adjusted divalproex sodium dosage on the basis of reports from blinded raters. Therefore, because the physician who controlled therapy knew which patients were receiving divalproex, the trial did not satisfy the criterion of concealed allocation. In Tariot 2001, 54% of the treated patients dropped out compared with 29% of control patients. Of all treated patients, 22% dropped out because of adverse effects, and the study had to be discontinued prematurely. The third trial (Sival 2002) had a cross-over design. No results from the first phase of the study were available, and although the statistical section stated, "the t-test for independent samples is used to analyze the two-period cross-over trial", because the samples were not independent - they are the same patients in the treatment and placebo groups - a question must be raised about the correctness of the analyses. The type of valproate used in the trials varied - one used short-acting sodium valproate, one long-acting divalproex sodium, and the third early-onset acting divalproex sodium. Average doses differed (480mg/d - 1000mg/d), as did duration of therapy (3 wks - 6 wks), and ways of evaluating patients and their response to therapy. A limited meta-analysis, pooling the results concerning adverse effects (Porsteinsson 2001, Tariot 2001) revealed the following: Sedation occurred more frequently in patients treated with valproic acid than in controls Urinary tract infection was more common among patients treated with valproic acid than controls Because of differences in identifying adverse effects it was not possible to pool other observations concerning adverse effects between the two studies that were examined.

REVIEWERS' CONCLUSIONS

The trials reviewed should be regarded as preliminary. Individual reports suggest that low dose sodium valproate is ineffective in treating agitation among demented patients, and that high dose divalproex sodium is associated with an unacceptable rate of adverse effects. More research on the use of valproate preparations for agitation of people with dementia is needed. On the basis of current evidence, valproate preparations cannot be recommended for the treatment of agitation in dementia.