Clinical Characteristics of PMS Co-Morbid with MDD and Effectiveness of SSRIs in its Treatment

Background: Data on the clinical characteristics of premenstrual syndrome (PMS) with co-morbid major depressive disorder (MDD) are scarce. Although selective serotonin re-uptake inhibitors (SSRIs) are widely used to treat both PMS and MDD there is little information on their efficacy in PMS in patients with co-morbid MDD.

Objective: To describe the clinical picture of PMS co-morbid with current depressive episode (DE) and evaluate its dynamics under a 6-month course of SSRIs treatment.

Materials and methods: We present a longitudinal observational study, conducted in out- and inpatient conditions. Thirty-one women eligible to antidepressant treatment for a current DE in the course of MDD were evaluated for PMS and those of them suffering from both conditions were re-evaluated twice during a 6-month medication intake period.

Results: The pre-treatment clinical picture of PMS co-morbid with MDD was dominated by moderately to severely expressed mood swings, anxiety, fatigue, breast tenderness, palpitations, abdominal bloating, and headache. After six months of SSRIs intake the syndrome was characterised by nearly the same symptoms (with the addition of irritability and appetite changes) but mildly expressed.

Conclusion: Untreated PMS co-morbid with MDD is characterised by mainly moderately severe psychological and around three times less commonly – somatic symptoms. SSRIs treatment alleviate both symptom types at month three and even further, although less pronouncedly at month six.

Lessons to be learnt from meta-analyses of newer versus older antidepressants

Meta-analysis is the use of statistical techniques to analyse the findings of many individual analyses (Glass, 1977). It covers all aspects of the review process involving formulating relevant research questions, searching the literature, assessing the quality of studies and choosing relevant ones, extracting and combining the data (for review see Henry & Wilson, 1992; Wilson & Henry, 1992). Meta-analysis as part of a systematic review has advantages over a narrative review but there are problems in applying it in practice (Box 1).

Therapy of bovine endometritis with prostaglandin F2α: a meta-analysis

The objective of the conducted meta-analysis was to assess the efficacy of the treatment of bovine endometritis with PGF(2α) by statistical means. Postpartum uterine infections have a high prevalence and a very negative effect on reproductive performance in dairy cattle. Because of a wide discordance between research results, a meta-analysis of the efficacy of the treatment of bovine endometritis with PGF(2α) was conducted. A comprehensive literature search was performed using online databases to reveal a total of 2,307 references. In addition, 5 articles were retrieved by reviewing citations. After applying specific exclusion criteria and evaluating specific evidence parameters, 5 publications, comprising 6 trials, were eligible for being analyzed by means of meta-analysis. Data for each trial were extracted and analyzed using meta-analysis software Review Manager (version 5.1; The Nordic Cochrane Centre, Copenhagen, Denmark). Estimated effect sizes of PGF(2α) were calculated on calving to first service and calving to conception interval. Prostaglandin F(2α) treatment of cows with chronic endometritis had a negative effect on both reproductive performance parameters. Heterogeneity was substantial for calving to first service and calving to conception interval [I(2) (measure of variation beyond chance)=100 and 87%, respectively]; therefore, random-effects models were used. Sensitivity analysis as well as subgroup analysis showed that the performance of randomization was influential in modifying effect size of PGF(2α) treatment. The funnel plot illustrated a publication bias toward smaller studies that reported a prolonged calving to conception interval after a PGF(2α) treatment. We conclude that the investigation of this subject by means of meta-analysis did not reveal an improvement of reproductive performance of cows with endometritis after treatment with PGF(2α). Furthermore, there is a shortage of comparable high quality studies investigating reproductive performance after PGF(2α) treatment of cows with chronic endometritis.

Neuraxial anesthesia compared to general anesthesia for procedures on the lower half of the body: systematic review of systematic reviews

BACKGROUND AND OBJECTIVES

Systematic reviews organize literature data by combining results from published studies in order to resolve conflicts in the area of medical knowledge describing the interventions. The inadequate reporting of systematic reviews can damage the credibility and interfere in the results' quality. The objective of this study was to determine the frequency of good quality systematic reviews comparing neuraxial anesthesia with general anesthesia for procedures on the lower half of the body.

METHODS

Systematic review of systematic reviews. Primary variable: The frequency of good quality systematic reviews. The information was analyzed from the following databases: LILACS (January 1982 to December 2010); PubMed (January 1950 to December 2010); The Cochrane Database of Systematic Review and Database of Abstracts of Reviews of Effects (volume 10, 2010); and SciELO (December 2010). The quality of systematic reviews was determined by the Overview Quality Assessment Questionnaire. The sample size calculation showed that it was necessary to analyze eight systematic reviews, taking into account that the frequency of good quality systematic reviews was 5%, an absolute precision of 15%, and a significance level of 5%.

RESULTS

Were identified 1,995 articles. The selection process eliminated 1,968 articles. Twenty-seven articles of systematic reviews were read in full, 9 were excluded due to incompatibility with the inclusion criteria, and 8 were duplicate publications. Ten systematic reviews were assessed for their quality. The frequency of good quality systematic reviews was 40% (4/10; 95% CI 9.6 to 70.4%).

CONCLUSION

The frequency of good quality systematic reviews was 40%.

A review of critical appraisal tools show they lack rigor: Alternative tool structure is proposed

OBJECTIVES

To evaluate critical appraisal tools (CATs) that have been through a peer-reviewed development process with the aim of analyzing well-designed, documented, and researched CATs that could be used to develop a comprehensive CAT.

STUDY DESIGN AND SETTING

A critical review of the development of CATs was undertaken.

RESULTS

Of the 44 CATs reviewed, 25 (57%) were applicable to more than one research design, 11 (25%) to true experimental studies, and the remaining 8 (18%) to individual research designs. Comprehensive explanation of how a CAT was developed and guidelines to use the CAT were available in five (11%) instances. There was no validation process reported in 11 CATs (25%) and 33 CATs (77%) had not been reliability tested. The questions and statements that made up each CAT were coded into 8 categories and 22 items such that each item was distinct from every other.

CONCLUSIONS

CATs are being developed while ignoring basic research techniques, the evidence available for design, and comprehensive validation and reliability testing. The basic structure for a comprehensive CAT is suggested that requires further study to verify its overall usefulness. Meanwhile, users of CATs should be careful about which CAT they use and how they use it.

Treatment of depression with atypical features: a meta-analytic approach

The present meta-analysis addressed the empirical evidence regarding the treatment of major depression with atypical features. The superiority of monoamine oxidase inhibitors (MAOIs) compared with other antidepressants in the treatment of major depression with atypical features has been frequently reported. According to the CONSORT Statement, studies included in our meta-analysis had to meet several criteria, especially a double-blind, controlled condition and an operational diagnosis according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-III or DSM-IV criteria, respectively. Four databases for research-based evidence were used in a systematic review: Medline, Embase, Psyndex and PsycInfo. Only eight publications met inclusion/exclusion criteria, resulting in 11 comparisons. Our results contrast an effect size of 0.45 (95% confidence interval) for a comparison of MAOIs vs. placebo with an effect size of 0.02 (95% confidence interval: - 0.10-0.14) for a comparison of MAOIs vs. selective serotonin reuptake inhibitors. The effect size for MAOIs vs. tricyclic antidepressants was 0.27 (95% confidence interval: 0.16-0.42). MAOIs may be more effective for atypical major depressive disorder than tricyclic antidepressants. Most clinical research has been conducted on irreversible MAOIs. Additional studies testing more recently developed antidepressants (including reversible MAOIs) with an improved safety profile would be warranted. The available data are insufficient for a direct comparison between MAOIs and selective serotonin reuptake inhibitors.

Evaluating the quality of systematic reviews in the emergency medicine literature

STUDY OBJECTIVE

The objective of this study was to examine the scientific quality of systematic reviews published in 5 leading emergency medicine journals.

METHODS

MEDLINE and EMBASE databases were electronically searched to identify published systematic reviews. Searches were only conducted in emergency medicine journals during the past 10 years; 4 of the journals were also hand searched. Potential reviews were assessed independently by 2 reviewers for inclusion. Data regarding methods were extracted from each review independently by 2 reviewers. All systematic reviews were retrieved and rated for quality by using the 10 questions from the overview quality assessment questionnaire.

RESULTS

Twenty-nine reviews were identified from more than 100 citations. The overall scientific quality of the systematic reviews was low (mean score, 2.7; 95% confidence interval 2.1 to 3.2; maximum possible score, 7.0). Selection and publication biases were rarely addressed in this collection of reviews. For example, the search strategies were only identified in 9 (31%) reviews, whereas independent study selection (6 [21%]) and quality assessment of included studies (9 [31%]) were infrequently performed. Overall, the majority of reviews had extensive flaws, and only 3 (10%) had minimal flaws.

CONCLUSION

The results of the study indicate that many of the systematic reviews published in the emergency medicine literature contain major flaws; reviews with poor methodology may limit the validity of reported results. Further efforts should be made to improve the design, reporting, and publication of systematic reviews in emergency medicine.

Meta-analytical studies on new antidepressants

A systematic search found 108 meta-analyses of the use of antidepressants in depressive disorders. Defining newer antidepressants as those introduced since the early 1980s, 18 meta-analyses were selected as being informative about their relative efficacy and tolerability in comparative randomised controlled studies (RCTs). Findings with higher confidence include: little difference in efficacy between most new and old antidepressants; superior efficacy of serotonin and noradrenaline re-uptake inhibitors (SNRIs) over selective serotonin re-uptake inhibitors (SSRIs); a slower onset of therapeutic action of fluoxetine over other SSRIs; a different side effect profile of SSRIs to TCAs with superior general tolerability of SSRIs over TCAs; poorer tolerability of fluvoxamine than other SSRIs in a within group comparison; no increased the risk of suicidal acts or ideation in fluoxetine compared with TCAs (or placebo) in low-risk patients. Findings with a lower level of confidence include: greater efficacy of TCAs than SSRIs in in-patients; greater efficacy of amitriptyline than SSRIs; better tolerability of moclobemide than TCAs; no demonstrable difference in tolerability between SSRIs and TCAs in the elderly; no better tolerability of fluvoxamine than TCAs; better tolerability of dothiepin (dosulepin) than SSRIs; better tolerability of sertraline and greater frequency of agitation on fluoxetine than other SSRIs in a within group comparison. In general, the meta-analyses were of uneven quality, as were the studies included, which limits the confidence in many of the results. Generalising from mostly short-term randomised controlled studies to clinical practice requires caution.

What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?

OBJECTIVE

Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups.

RESULTS

Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability.

CONCLUSIONS

Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.

Interventions for psoriatic arthritis

OBJECTIVES

To assess the effects of salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis.

SEARCH STRATEGY

We searched Medline up to 1995, and Excerpta Medica (June 1974-95). Search terms were psoriasis, arthritis, therapy and/or controlled trial. This was supplemented by manually searching bibliographies of previously published reviews, conference proceedings and contacting drug companies. All languages were included in the initial search.

SELECTION CRITERIA

All randomized trials comparing salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis. The main outcome measures included individual component variables derived from Outcome Measures in Rheumatology Clinical Trials (OMERACT). These include Acute Phase Reactants, Disability, Pain, Patient Global Assessment, Physician Global Assessment, Swollen joint count, Tender joint count and radiographic changes of joints in any trial of 1 year or longer [Tugwell 1993], and the change in pooled disease index. Only English trials were included in the review.

DATA COLLECTION AND ANALYSIS

Data were independently extracted from the published reports by two of the reviewers. An independent blinded quality assessment was also performed.

MAIN RESULTS

Nineteen randomized trials were identified of which eleven were included in the quantitative analysis with data from 777 subjects. Although all agents were better than placebo, parenteral high dose methotrexate (not included), salazopyrin, azathioprine and etretinate were the agents that achieved statistical significance in a global index of disease activity (although it should be noted that only one component variable was available for azathioprine and only one trial was available for etretinate suggesting some caution is necessary in interpreting these results). Analysis of response in individual disease activity markers was more variable with considerable differences between different medications and responses. In all trials the placebo group improved over baseline (pooled improvement 0.43 DI units, 95% CI 0. 28-0.59). There was insufficient data to examine toxicity.

REVIEWER'S CONCLUSIONS

Parenteral high dose methotrexate and salazopyrin are the only two agents with well demonstrated published efficacy in psoriatic arthritis. The magnitude of the effect seen with azathioprine, etretinate, oral low dose methotrexate and perhaps colchicine suggests that they may be effective but that further multicentre clinical trials are required to establish their efficacy. Furthermore, the magnitude of the improvement observed in the placebo group strongly suggests that uncontrolled trials should not be used to guide management decisions in this condition.

Discontinuation rates of Helicobacter pylori treatment regimens: a meta-analysis

We conducted a meta-analysis to determine what factors in treatment regimens for Helicobacter pylori are associated with increased discontinuation rates. Studies were selected from the 1990-1996 MEDLINE data base, and references in published articles and reviews were obtained. Each article was uniformally abstracted for factors that could potentially affect dropout rates. Drug regimens with high numbers of doses per day had highest dropout rates (p=0.0001). The total dropout rate was lowest for regimens containing a proton pump inhibitor (OR = 0.75, CI 0.57, 0.98). The rate was high in regimens containing a bismuth compound due to side effects (OR = 2.79, CI 1.78, 4.36). The main finding was that drug regimens for eradication of H. pylori that have a high number of doses per day result in higher discontinuation rates than regimens with fewer doses per day.

Gonadotrophin-releasing hormone in postpartum dairy cattle: a meta-analysis of effects on reproductive efficiency

The efficacy of gonadotrophin-releasing hormone (GnRH) or synthetic analogues in improving the reproductive performance of dairy cows less than 40 days postpartum has not been established. It was postulated that disparity observed between the results of similar trials may have arisen from differences in study design, including the dosage of GnRH used; the number of days after calving at which GnRH was administered; the concurrent use of prostaglandins to induce oestrus; and the enrollment of cows with an abnormal puerperium. The results of 24 trials, extracted from 12 research papers were assessed using meta-analysis. When all trials were considered, treatment with GnRH did not significantly alter the number of days to first oestrus or first service or the relative risk of pregnancy at first service (P > 0.05). While treatment did significantly reduce the number of days open by 2.75 days and the number of services per conception by 0.05 services, the results of these studies were heterogenous (P < 0.001) and the validity of pooled estimates questionable. The results of the subgroup of studies that enrolled only cows with a normal puerperium were homogenous for all outcomes examined (P > 0.43), although none of the pooled estimates were significant. Sensitivity analyses, performed by excluding the consistently outlying results of one study, improved the homogeneity of all outcomes (P > 0.03) and produced a significant reduction of 4.52 days to first oestrus in treated cows. Pooled estimates derived without the results of the outlying study were considered more valid indicators of the direction and likely magnitude of effect than those derived in the heterogenous overall analyses. The results of this meta-analysis showed that while blanket treatment of dairy cows in the postpartum period may reduce the number of days to first oestrus, subsequent reproductive performance is unaltered. The study also demonstrated a need to concentrate further research on the potential for treatment with GnRH during the postpartum period to improve the reproductive performance of cows with an abnormal puerperium.

Discontinuation rates of SSRIs and tricyclic antidepressants: a meta-analysis and investigation of heterogeneity

BACKGROUND

Previous meta-analyses suggest that individuals treated with serotonin-specific reuptake inhibitors (SSRIs) in randomised controlled trials (RCTs) are less likely to discontinue treatment than those on tricyclic antidepressants. This metaanalysis investigates whether this is due to the frequent use in RCTs of older reference tricyclics (imipramine and amitriptyline), which may have worse side-effects than more recent compounds.

METHODS

A meta-analysis of RCTs comparing tricyclic and heterocyclic antidepressants with SSRIs in the treatment of depression.

RESULTS

The overall odds ratio of discontinuation on tricyclic/heterocyclic antidepressants compared with SSRIs was 0.86 (95% CI 0.78-0.94). The odds ratio for reference tricyclics was 0.82 95% CI 0.72-0.23), newer tricyclics 0.89 (95% CI 0.74-1.06), and heterocyclics 1.02 (95% CI 0.78-1.35). The pooled advantage of SSRIs over tricyclics was maintained whether the population studied consisted of younger adults or only the elderly. No differences in discontinuation rates were detected between the SSRIs.

CONCLUSIONS

The lower rate of discontinuation in patients on SSRIs may be due to the use of old tricyclics (which have worse side-effects) as reference compounds. The SSRIs do not show a statistically significant difference in discontinuation rates when compared with newer tricyclics or heterocyclics.

How to systematically review the medical literature

In contrast to traditional narrative reviews, systematic reviews are true hypothesis-driven research. Meta-analysis is a form of systematic review in which studies are selected and combined by use of a predefined protocol to reduce bias and subjectivity. A sensitivity analysis shows how results vary through the use of different assumptions, tests, and criteria. The most valid synthesis of information occurs when published and unpublished materials are subjected to the same rigorous evaluation and when results are calculated with and without unpublished sources of data. A good systematic review captures the reader's attention through a skillful blend of numbers and narrative and qualifies for publication as original research in a peer-reviewed journal. Otolaryngologists have published systematic reviews of varying quality since 1990. This article should help improve the quality and validity of future efforts.

Nebulised antipseudomonal antibiotic therapy in cystic fibrosis: a meta-analysis of benefits and risks

BACKGROUND

To establish the benefits and risks of nebulised antipseudomonal therapy in cystic fibrosis the results of relevant randomised controlled trials were combined.

METHODS

The therapeutic end points compared were (a) number of pulmonary exacerbations requiring treatment with systemic antibiotics, (b) measurable alteration in respiratory tract pseudomonal load, (c) alteration in lung function on spirometric assessment, (d) development of resistance in respiratory tract Pseudomonas strains to the nebulised antipseudomonal used in each randomised controlled trial, and (e) renal and auditory impairment.

RESULTS

Five studies were suitable for meta-analysis, eight others could not be included because of inadequate outcome description or the lack of appropriate randomisation. Meta-analysis shows benefit for nebulised antipseudomonal antibiotic therapy with no demonstrable adverse effect other than a possible increase in in vitro antibiotic resistance of Pseudomonas aeruginosa of the respiratory tract.

CONCLUSIONS

Although inferences drawn from individual randomised controlled trials concerning the benefits and risks of this form of therapy are conflicting, pooled effect size establishes benefit with nebulised antipseudomonal antibiotic therapy and emphasises its relevance to the integration of information in other areas of controversy relating to the treatment of this disease.

Thiazide diuretics and fractures: can meta-analysis help?

Published observational estimates of the effect of thiazide diuretics on osteoporotic fracture risk vary from a 70% reduction to a 60% increase but there have been no randomized controlled trials. The aims of this study were to use the technique of meta-analysis to attempt to resolve this conflict and to explore whether duration and/or dose of therapy has an effect on osteoporotic fracture risk. The data sources utilized were Medline and Excerpta Medica databases supplemented by reviews and back references. A total of 18 observational studies that looked at the relationship between diuretics and fracture were located, of which 13, involving 29,600 subjects, had extractable data on thiazides and fracture occurrence. Current thiazide users were protected against hip fracture (OR 0.82, 95% CI 0.73-0.91). Thiazide use of long duration may be protective (OR 0.82, 95% CI 0.62-1.08) but not short duration (OR 1.23, 95% CI 0.99-1.54). The size of this effect, which compares favorably to other interventions, indicates that a randomized controlled trial to resolve the problem of potential confounders and safety profile would require a minimum of 7000 person-years of observation in those at highest risk of fracture (women aged 80 or over) which is unlikely to be pursued at the present time. The results of this meta-analysis indicate that current thiazide users have a 20% reduction in fracture risk and that long-term use may reduce fractures by a similar amount.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of prophylactic antibiotics for craniotomy: a meta-analysis

A meta-analysis of published randomized studies comparing prophylactic antibiotics to placebo in craniotomies was performed. Ten studies were examined; eight met criteria for inclusion into the meta-analysis. The analysis showed an advantage of antibiotics over placebo at the P < 10-8 level. Tests for homogeneity of effect size between the individual studies showed similar effects of antibiotic treatment between trials, despite variation in the randomization methods and antibiotic regimens used. No statistically significant difference was detected between antibiotic regimens that did or did not cover gram-negative organisms or between single- and multiple-dose regimens. Cumulative meta-analyses showed that this conclusion could have been confidently drawn by 1988, after only four of the eight eligible trials had been published. Trials published since that time have reinforced these conclusions but have not significantly altered them. Future studies should compare proposed new antibiotic regimens with one of those already demonstrated to be effective, not with a placebo.

A public health nurse's guide to reading meta-analysis research reports

Meta-analysis research reports are increasingly found in the public health literature. Meta-analysis is a quantitative method for summarizing existing studies. Although it is often advocated to synthesize research, nurses must be able to read these reports critically to determine applicability to practice.

Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials

OBJECTIVE

To reconcile conflicting published reports concerning the absolute and comparative clinical efficacy of antimicrobial drugs for acute otitis media in children.

STUDY SELECTION

Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Randomized, controlled trials of therapeutic antimicrobial drugs used in the initial empiric therapy for simple acute otitis media were selected by independent, blinded observers, and scored on 11 measures of study validity. Thirty English and three foreign-language articles met all inclusion criteria.

DATA EXTRACTION

Data were abstracted for an end point of complete clinical resolution (primary control), exclusive of middle ear effusion, within 7 to 14 days after therapy started.

DATA SYNTHESIS

The spontaneous rate of primary control--without antibiotics or tympanocentesis--was 81% (95% confidence interval, 69% to 94%). Compared with placebo or no drug, antimicrobial therapy increased primary control by 13.7% (95% confidence interval, 8.2% to 19.2%). No significant differences were found in the comparative efficacy of various antimicrobial agents. Extending antimicrobial coverage to include beta-lactamase-producing organisms did not significantly increase the rates of primary control or resolution of middle ear effusion. Pretreatment tympanocentesis was positively associated with individual group primary control rates, negatively associated with the ability to detect differences in clinical efficacy and unassociated with resolution of MEE.

CONCLUSIONS

Antimicrobial drugs have a modest but significant impact on the primary control of acute otitis media. Treatment with beta-lactamase-stable agents does not increase resolution of acute symptoms or middle ear effusion; initial therapy should be guided by considerations of safety, tolerability, and affordability, and not by the theoretical advantage of an extended antibacterial spectrum.

The efficacy of selective serotonin re-uptake inhibitors in depression: a meta-analysis of studies against tricyclic antidepressants

A meta-analysis of the efficacy of five selective serotonin re-uptake inhibitors (SSRIs) against non-selective and noradrenergic re-uptake inhibitors (mainly tricyclic antidepressants, TCAs) is presented. Fifty five double- blind studies were identified after excluding those multiply reported or with methodological problems likely to bias the outcome in favour of SSRIs. Standardised effect sizes and 95% confidence intervals were calculated based on the difference in the reduction in mean Hamilton depression rating scale (HDRS) scores for the two antidepressants. For studies not reporting standard deviations, the pooled variance from complete studies was used and a variance-weighted mean effect size calculated. There were no differences in efficacy between SSRIs and comparator antidepressants for SSRIs taken together or individually. If studies were classified into high and low depression scores based on a median split of initial HDRS scores, there was a slight advantage to TCAs in the high HDRS group. In addition, SSRIs were slightly less effective than TCAs in in-patients and against combined serotonin and noradrenaline re-uptake inhibitors (clomipramine and amitriptyline). These findings were accounted for by a clinically significant lower efficacy of paroxetine in these subgroups. In contrast, SSRIs as a group were marginally more effective than noradrenergic antidepressants, a finding accounted for by two studies with sertraline. Fluvoxamine was the only SSRI to have been tested adequately in in-patients, where it displayed equal efficacy to TCAs. This meta-analysis confirms that SSRIs and TCAs are in general equally effective, but suggests that paroxetine's efficacy in in-patients and against clomipramine and amitriptyline is not proven.

A quantitative evaluation of the aetiological role of betel quid in oral carcinogenesis

Computer aided search and review of bibliographies of published papers and monographs revealed 17 case control studies of oral cancer and betel quid chewing from 1933 to 1990. Studies were assessed and site specific risk of oral cancer associated with chewing betel quid with and without tobacco in the quid among smokers and non-smokers was computed. Tobacco smoking and chewing betel quid containing tobacco arose as important risk factors for oral cancer, betel quid without tobacco significantly increased risk in only one study. Heterogeneity in estimates of risk among studies was reduced by restricting analysis to those with more exact definition of exposure and site of the cancer. Variation in risk among studies reflects bias in selection and inadequate definition of exposure and tumour site and an inability to control effectively for confounding. Further studies, addressing these issues are advised, to clarify the role of betel quid without tobacco as a carcinogen, alone and in combination with tobacco smoke.

Yttrium synovectomy: a meta-analysis of the literature

BACKGROUND

Yttrium synovectomy for chronic synovitis of the knee enjoys widespread usage in Australia with approximately 400 patients receiving yttrium-90 in 1991. Despite abundant anecdotal evidence of its efficacy there is a paucity of controlled trials and those that have been done have produced conflicting results and have been of insufficient sample size.

AIMS

To critically and quantitatively evaluate the published English literature on comparative trials of yttrium-90 therapy for chronic synovitis of the knee.

METHODS

The technique of meta-analysis was utilised. The literature search was carried out using the MeSH terms of synovectomy and knee; and yttrium. This was augmented by referring to reviews, current textbooks and back-references. Outcome measures varied between trials but could be grouped as treatment success. The Peto modification of Mantel and Haenszl was used for statistical pooling of data yielding a pooled odds ratio (OR).

RESULTS

The literature search revealed ten controlled trials of which two were excluded from further analysis. Yttrium was superior to placebo (OR 2.42, 95% CI 1.02-5.73) but this result should be interpreted with caution due to possible publication bias. Yttrium was not superior to triamcinolone (OR 1.89, 95% CI 0.81-10.55) or other active modalities (OR 1.04, 95% CI 0.72-1.52). Further research comparing yttrium with other modalities is necessary to properly determine its place in rheumatological practice.