A meta-epidemiological study of bias in randomized clinical trials of open and laparoscopic surgery

BACKGROUND

Blinding, random sequence generation, and allocation concealment are established strategies to minimize bias in RCTs. Meta-epidemiological studies of drug trials have demonstrated exaggerated treatment effects in RCTs where such methods were not employed. As blinding is more difficult in surgical trials it is important to determine whether this applies to them. The study aimed to investigate this using systematic meta-epidemiological methods.

METHOD

The Cochrane Database of Systematic Reviews was searched for systematic reviews of RCTs that compared laparoscopic and open abdominal surgical procedures. Each review was then scrutinized to determine whether at least one of the included trials was blinded. Eligible reviews were updated and individual RCTs retrieved. Extracted data included the primary outcomes of interest (length of stay and complications), secondary outcomes and a risk of bias assessment. A multistep meta-regression analysis was then performed to obtain an overall difference in the reported outcome differences between trials that employed each bias-minimization strategy, and those that did not.

RESULTS

Some 316 RCTs were included, reporting on eight different procedures. Patient-blinded RCTs reported a smaller difference in length of stay between laparoscopic and open groups (difference of standardized mean differences -0·36 (95 per cent c.i. -0·73 to 0·00)) and complications (ratio of odds ratios 0·76 (95 per cent c.i. 0·61 to 0·93)). Blinding of postoperative carers and outcome assessors had similar effects.

CONCLUSION

Lack of blinding significantly altered the treatment effect estimates of RCTs comparing laparoscopic and open surgery. Blinding should be implemented in surgical RCTs where possible to avoid systematic bias.

Placebo run-in periods in anticholinergic trials are not associated with treatment effect size or risk of attrition: an empirical evaluation

OBJECTIVES

We aimed to explore the impact of run-in periods on the magnitude of treatment effect and the risk of attrition in a sample of randomized trials.

STUDY DESIGN AND SETTING

We identified randomized trials from a published systematic review examining the effects of anticholinergics for the treatment of overactive bladders. We fitted meta-analytic mixed-effects models to assess whether the type of run-in (placebo run-in vs. no run-in) was associated with the magnitude of the effect estimates for the following outcomes: the number of voids per day, number of leakages per day, presence of dry mouth, cure/improvement, patient withdrawal from the trial, compliance with the trial protocol, and/or adherence to study drug. We adjusted for potential confounders.

RESULTS

A total of 96 trials met the eligibility criteria; 59 trials had no run-in (which included those with a screening or withdrawal period), 37 trials had a placebo run-in, and no trials had a drug run-in. The magnitude of the effect estimates for all outcomes did not importantly differ between trials with a placebo run-in and trials with no run-in. Adjustment for the confounding variables did not materially change the estimates.

CONCLUSION

The hypothesized benefits of placebo run-in periods were not observed in our sample of anticholinergic randomized trials for the treatment of overactive bladders. Designing future trials of anticholinergics with more pragmatic intentions is likely to result in evidence that more directly informs clinical decision-making.

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

OBJECTIVES

To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.

DESIGN

A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance.

SETTING

Medical, surgical and intensive care units of a district general hospital.

OUTCOMES

The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method.

RESULTS

289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).

CONCLUSIONS

The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.

Network meta-analysis of surgical management of gastro-oesophageal reflux disease in adults

BACKGROUND

Proton pump inhibitors are the mainstay of treatment for gastro-oesophageal reflux disease, but are associated with ongoing costs and side-effects. Antireflux surgery is cost-effective and is preferred by many patients. A total (360^o or Nissen) fundoplication is the traditional procedure, but other variations including partial fundoplications are also commonly performed, with the aim of achieving durable reflux control with minimal dysphagia. Many RCTs and some pairwise meta-analyses have compared some of these procedures but there is still uncertainty about which, if any, is superior. Network meta-analysis allows multiple simultaneous comparisons and robust synthesis of the available evidence in these situations. A network meta-analysis comparing all antireflux procedures was performed to identify which has the most favourable outcomes at short-term (3-12 months), medium-term (1-5 years) and long-term (10 years and more than 10 years) follow-up.

METHODS

Article databases were searched systematically for all eligible RCTs. Primary outcomes were quality-of-life measures and dysphagia. Secondary outcomes included reflux symptoms, pH studies and complications.

RESULTS

Fifty-one RCTs were included, involving 5357 patients and 14 different treatments. Posterior partial fundoplication ranked best in terms of reflux symptoms, and caused less dysphagia than most other interventions including Nissen fundoplication. This was consistent across all time points and outcome measures.

CONCLUSION

Posterior partial fundoplication provides the best balance of long-term, durable reflux control with less dysphagia, compared with other treatments.

Transcutaneous electrical nerve stimulation (TENS) for fibromyalgia in adults

BACKGROUND

Fibromyalgia is characterised by persistent, widespread pain; sleep problems; and fatigue. Transcutaneous electrical nerve stimulation (TENS) is the delivery of pulsed electrical currents across the intact surface of the skin to stimulate peripheral nerves and is used extensively to manage painful conditions. TENS is inexpensive, safe, and can be self-administered. TENS reduces pain during movement in some people so it may be a useful adjunct to assist participation in exercise and activities of daily living. To date, there has been only one systematic review in 2012 which included TENS, amongst other treatments, for fibromyalgia, and the authors concluded that TENS was not effective.

OBJECTIVES

To assess the analgesic efficacy and adverse events of TENS alone or added to usual care (including exercise) compared with placebo (sham) TENS; no treatment; exercise alone; or other treatment including medication, electroacupuncture, warmth therapy, or hydrotherapy for fibromyalgia in adults.

SEARCH METHODS

We searched the following electronic databases up to 18 January 2017: CENTRAL (CRSO); MEDLINE (Ovid); Embase (Ovid); CINAHL (EBSCO); PsycINFO (Ovid); LILACS; PEDRO; Web of Science (ISI); AMED (Ovid); and SPORTDiscus (EBSCO). We also searched three trial registries. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised trials of TENS treatment for pain associated with fibromyalgia in adults. We included cross-over and parallel-group trial designs. We included studies that evaluated TENS administered using non-invasive techniques at intensities that produced perceptible TENS sensations during stimulation at either the site of pain or over nerve bundles proximal (or near) to the site of pain. We included TENS administered as a sole treatment or TENS in combination with other treatments, and TENS given as a single treatment or as a course of treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined study eligibility by assessing each record and reaching agreement by discussion. A third review author acted as arbiter. We did not anonymise the records of studies before assessment. Two review authors independently extracted data and assessed risk of bias of included studies before entering information into a 'Characteristics of included studies' table. Primary outcomes were participant-reported pain relief from baseline of 30% or greater or 50% or greater, and Patient Global Impression of Change (PGIC). We assessed the evidence using GRADE and added 'Summary of findings' tables.

MAIN RESULTS

We included eight studies (seven RCTs, one quasi-RCT, 315 adults (299 women), aged 18 to 75 years): six used a parallel-group design and two used a cross-over design. Sample sizes of intervention arms were five to 43 participants.Two studies, one of which was a cross-over design, compared TENS with placebo TENS (82 participants), one study compared TENS with no treatment (43 participants), and four studies compared TENS with other treatments (medication (two studies, 74 participants), electroacupuncture (one study, 44 participants), superficial warmth (one cross-over study, 32 participants), and hydrotherapy (one study, 10 participants)). Two studies compared TENS plus exercise with exercise alone (98 participants, 49 per treatment arm). None of the studies measured participant-reported pain relief of 50% or greater or PGIC. Overall, the studies were at unclear or high risk of bias, and in particular all were at high risk of bias for sample size.Only one study (14 participants) measured the primary outcome participant-reported pain relief of 30% or greater. Thirty percent achieved 30% or greater reduction in pain with TENS and exercise compared with 13% with exercise alone. One study found 10/28 participants reported pain relief of 25% or greater with TENS compared with 10/24 participants using superficial warmth (42 °C). We judged that statistical pooling was not possible because there were insufficient data and outcomes were not homogeneous.There were no data for the primary outcomes participant-reported pain relief from baseline of 50% or greater and PGIC.There was a paucity of data for secondary outcomes. One pilot cross-over study of 43 participants found that the mean (95% confidence intervals (CI)) decrease in pain intensity on movement (100-mm visual analogue scale (VAS)) during one 30-minute treatment was 11.1 mm (95% CI 5.9 to 16.3) for TENS and 2.3 mm (95% CI 2.4 to 7.7) for placebo TENS. There were no significant differences between TENS and placebo for pain at rest. One parallel group study of 39 participants found that mean ± standard deviation (SD) pain intensity (100-mm VAS) decreased from 85 ± 20 mm at baseline to 43 ± 20 mm after one week of dual-site TENS; decreased from 85 ± 10 mm at baseline to 60 ± 10 mm after single-site TENS; and decreased from 82 ± 20 mm at baseline to 80 ± 20 mm after one week of placebo TENS. The authors of seven studies concluded that TENS relieved pain but the findings of single small studies are unlikely to be correct.One study found clinically important improvements in Fibromyalgia Impact Questionnaire (FIQ) subscales for work performance, fatigue, stiffness, anxiety, and depression for TENS with exercise compared with exercise alone. One study found no additional improvements in FIQ scores when TENS was added to the first three weeks of a 12-week supervised exercise programme.No serious adverse events were reported in any of the studies although there were reports of TENS causing minor discomfort in a total of 3 participants.The quality of evidence was very low. We downgraded the GRADE rating mostly due to a lack of data; therefore, we have little confidence in the effect estimates where available.

AUTHORS' CONCLUSIONS

There was insufficient high-quality evidence to support or refute the use of TENS for fibromyalgia. We found a small number of inadequately powered studies with incomplete reporting of methodologies and treatment interventions.

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) imposes significant health and economic burden on society and the women affected. Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with SUI, with the presumed advantages of avoiding major incisions, shorter hospital stays and quicker return to normal activities.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 2 July 2009), and sought additional trials from other sources and by contacting study authors for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery as the intervention in at least one arm of the studies.

DATA COLLECTION AND ANALYSIS

The review authors evaluated trials for methodological quality and their appropriateness for inclusion in the review. Two review authors extracted data and another cross checked them. Where appropriate, we calculated a summary statistic.

MAIN RESULTS

We identified 22 eligible trials. Ten involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures, in the short- and medium-term follow-up, there was some evidence of poorer results of laparoscopic colposuspension on objective outcomes. The results showed trends towards fewer perioperative complications, less postoperative pain and shorter hospital stay for laparoscopic compared with open colposuspension, however, laparoscopic colposuspension was more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. There were no significant differences in the reported short- and long-term subjective cure rates of the two procedures but objective cure rates at 18 months favoured slings. We observed no significant differences for postoperative voiding dysfunction and perioperative complications. Laparoscopic colposuspension had a significantly longer operation time and hospital stay. We found significantly higher subjective and objective one-year cure rates for women randomised to two paravaginal sutures compared with one suture in a single trial. Three studies compared sutures with mesh and staples for laparoscopic colposuspension and showed a trend towards favouring the use of sutures.

AUTHORS' CONCLUSIONS

Currently available evidence suggests that laparoscopic colposuspension may be as good as open colposuspension at two years post surgery. However, the newer vaginal sling procedures appear to offer even greater benefits, better objective outcomes in the short term and similar subjective outcomes in the longer term. If laparoscopic colposuspension is performed, the use of two paravaginal sutures appears to be the most effective method. The place of laparoscopic colposuspension in clinical practice should become clearer when there are more data available describing long-term results. A brief economic commentary (BEC) identified three studies suggesting that tension-free vaginal tape (TVT) may be more cost-effective compared with laparoscopic colposuspension but laparoscopic colposuspension may be slightly more cost-effective when compared with open colposuspension after 24 months follow-up.

An investigation of the impact of using different methods for network meta-analysis: a protocol for an empirical evaluation

BACKGROUND

Network meta-analysis, a method to synthesise evidence from multiple treatments, has increased in popularity in the past decade. Two broad approaches are available to synthesise data across networks, namely, arm- and contrast-synthesis models, with a range of models that can be fitted within each. There has been recent debate about the validity of the arm-synthesis models, but to date, there has been limited empirical evaluation comparing results using the methods applied to a large number of networks. We aim to address this gap through the re-analysis of a large cohort of published networks of interventions using a range of network meta-analysis methods.

METHODS

We will include a subset of networks from a database of network meta-analyses of randomised trials that have been identified and curated from the published literature. The subset of networks will include those where the primary outcome is binary, the number of events and participants are reported for each direct comparison, and there is no evidence of inconsistency in the network. We will re-analyse the networks using three contrast-synthesis methods and two arm-synthesis methods. We will compare the estimated treatment effects, their standard errors, treatment hierarchy based on the surface under the cumulative ranking (SUCRA) curve, the SUCRA value, and the between-trial heterogeneity variance across the network meta-analysis methods. We will investigate whether differences in the results are affected by network characteristics and baseline risk.

DISCUSSION

The results of this study will inform whether, in practice, the choice of network meta-analysis method matters, and if it does, in what situations differences in the results between methods might arise. The results from this research might also inform future simulation studies.

Network meta-analysis of the effect of preoperative carbohydrate loading on recovery after elective surgery

BACKGROUND

Three meta-analyses have summarized the effects of preoperative carbohydrate administration on postoperative outcomes in adult patients undergoing elective surgery. However, these studies could not account for the different doses of carbohydrate administered and the different controls used. Multiple-treatments meta-analysis allows robust synthesis of all available evidence in these situations.

METHODS

Article databases were searched systematically for RCTs comparing preoperative carbohydrate administration with water, a placebo drink, or fasting. A four-treatment multiple-treatments meta-analysis was performed comparing two carbohydrate dose groups (low, 10-44 g; high, 45 g or more) with two control groups (fasting; water or placebo). Primary outcomes were length of hospital stay and postoperative complication rate. Secondary outcomes included postoperative insulin resistance, vomiting and fatigue.

RESULTS

Some 43 trials involving 3110 participants were included. Compared with fasting, preoperative low-dose and high-dose carbohydrate administration decreased postoperative length of stay by 0·4 (95 per cent c.i. 0·03 to 0·7) and 0·2 (0·04 to 0·4) days respectively. There was no significant decrease in length of stay compared with water or placebo. There was no statistically significant difference in the postoperative complication rate, or in most of the secondary outcomes, between carbohydrate and control groups.

CONCLUSION

Carbohydrate loading before elective surgery conferred a small reduction in length of postoperative hospital stay compared with fasting, and no benefit in comparison with water or placebo.

Impact of analysing continuous outcomes using final values, change scores and analysis of covariance on the performance of meta-analytic methods: a simulation study

When meta-analysing intervention effects calculated from continuous outcomes, meta-analysts often encounter few trials, with potentially a small number of participants, and a variety of trial analytical methods. It is important to know how these factors affect the performance of inverse-variance fixed and DerSimonian and Laird random effects meta-analytical methods. We examined this performance using a simulation study. Meta-analysing estimates of intervention effect from final values, change scores, ANCOVA or a random mix of the three yielded unbiased estimates of pooled intervention effect. The impact of trial analytical method on the meta-analytic performance measures was important when there was no or little heterogeneity, but was of little relevance as heterogeneity increased. On the basis of larger than nominal type I error rates and poor coverage, the inverse-variance fixed effect method should not be used when there are few small trials. When there are few small trials, random effects meta-analysis is preferable to fixed effect meta-analysis. Meta-analytic estimates need to be cautiously interpreted; type I error rates will be larger than nominal, and confidence intervals will be too narrow. Use of trial analytical methods that are more efficient in these circumstances may have the unintended consequence of further exacerbating these issues. © 2015 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd. © 2015 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd.

Reiki for depression and anxiety

BACKGROUND

Anxiety and depression affect many people. Treatments do not have complete success and often require people to take drugs for long periods of time. Many people look for other treatments that may help. One of those is Reiki, a 2500 year old treatment described as a vibrational or subtle energy therapy, and is most commonly facilitated by light touch on or above the body. There have been reports of Reiki alleviating anxiety and depression, but no specific systematic review.

OBJECTIVES

To assess the effectiveness of Reiki for treating anxiety and depression in people aged 16 and over.

SEARCH METHODS

Search of the Cochrane Register of Controlled Trials (CENTRAL - all years), the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR - all years), EMBASE, (1974 to November 2014), MEDLINE (1950 to November 2014), PsycINFO (1967 to November 2014) and AMED (1985 to November 2014). Additional searches were carried out on the World Health Organization Trials Portal (ICTRP) together with ClinicalTrials.gov to identify any ongoing or unpublished studies. All searches were up to date as of 4 November 2014.

SELECTION CRITERIA

Randomised trials in adults with anxiety or depression or both, with at least one arm treated with Reiki delivered by a trained Reiki practitioner.

DATA COLLECTION AND ANALYSIS

The two authors independently decided on inclusion/exclusion of studies and extracted data. A prior analysis plan had been specified but was not needed as the data were too sparse.

MAIN RESULTS

We found three studies for inclusion in the review. One recruited males with a biopsy-proven diagnosis of non-metastatic prostate cancer who were not receiving chemotherapy and had elected to receive external-beam radiation therapy; the second study recruited community-living participants who were aged 55 years and older; the third study recruited university students.These studies included subgroups with anxiety and depression as defined by symptom scores and provided data separately for those subgroups. As this included only 25 people with anxiety and 17 with depression and 20 more with either anxiety or depression, but which was not specified, the results could only be reported narratively. They show no evidence that Reiki is either beneficial or harmful in this population. The risk of bias for the included studies was generally rated as unclear or high for most domains, which reduces the certainty of the evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence to say whether or not Reiki is useful for people over 16 years of age with anxiety or depression or both.

Preoperative carbohydrate treatment for enhancing recovery after elective surgery

BACKGROUND

Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast-track surgery protocols. Although fast-track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis.

OBJECTIVES

To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data.

SELECTION CRITERIA

We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis.

MAIN RESULTS

We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I-II or I-III.A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding.In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low-quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference -0.13 days; 95% CI -0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high-quality evidence).As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low-quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation.

AUTHORS' CONCLUSIONS

Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases.

Preoperative carbohydrate treatment for enhancing recovery after elective surgery

BACKGROUND

Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast-track surgery protocols. Although fast-track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis.

OBJECTIVES

To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data.

SELECTION CRITERIA

We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis.

MAIN RESULTS

We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I-II or I-III.A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding.In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low-quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference -0.13 days; 95% CI -0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high-quality evidence).As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low-quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation.

AUTHORS' CONCLUSIONS

Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases.

Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery

BACKGROUND

Major abdominal surgery can be associated with a number of serious complications that may impair patient recovery. In particular, postoperative pulmonary complications (PPCs), including respiratory complications such as atelectasis and pneumonia, are a major contributor to postoperative morbidity and may even contribute to increased mortality. Continuous positive airway pressure (CPAP) is a type of therapy that uses a high-pressure gas source to deliver constant positive pressure to the airways throughout both inspiration and expiration. This approach is expected to prevent some pulmonary complications, thus reducing mortality.

OBJECTIVES

To determine whether any difference can be found in the rate of mortality and adverse events following major abdominal surgery in patients treated postoperatively with CPAP versus standard care, which may include traditional oxygen delivery systems, physiotherapy and incentive spirometry.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 9; Ovid MEDLINE (1966 to 15 September 2013); EMBASE (1988 to 15 September 2013); Web of Science (to September 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (to September 2013).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) in which CPAP was compared with standard care for prevention of postoperative mortality and adverse events following major abdominal surgery. We included all adults (adults as defined by individual studies) of both sexes. The intervention of CPAP was applied during the postoperative period. We excluded studies in which participants had received PEEP during surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies that met the selection criteria from all studies identified by the search strategy. Two review authors extracted the data and assessed risk of bias separately, using a data extraction form. Data entry into RevMan was performed by one review author and was checked by another for accuracy. We performed a limited meta-analysis and constructed a summary of findings table.

MAIN RESULTS

We selected 10 studies for inclusion in the review from 5236 studies identified in the search. These 10 studies included a total of 709 participants. Risk of bias for the included studies was assessed as high in six studies and as unclear in four studies.Two RCTs reported all-cause mortality. Among 413 participants, there was no clear evidence of a difference in mortality between CPAP and control groups, and considerable heterogeneity between trials was noted (risk ratio (RR) 1.28, 95% confidence interval (CI) 0.35 to 4.66; I(2) = 75%).Six studies reported demonstrable atelectasis in the study population. A reduction in atelectasis was observed in the CPAP group, although heterogeneity between studies was substantial (RR 0.62, 95% CI 0.45 to 0.86; I(2) = 61%). Pneumonia was reported in five studies, including 563 participants; CPAP reduced the rate of pneumonia, and no important heterogeneity was noted (RR 0.43, 95% CI 0.21 to 0.84; I(2) = 0%). The number of participants identified as having serious hypoxia was reported in two studies, with no clear difference between CPAP and control groups, given imprecise results and substantial heterogeneity between trials (RR 0.48, 95% CI 0.22 to 1.02; I(2) = 67%). A reduced rate of reintubation was reported in the CPAP group compared with the control group in two studies, and no important heterogeneity was identified (RR 0.14, 95% CI 0.03 to 0.58; I(2) = 0%). Admission into the intensive care unit (ICU) for invasive ventilation and supportive care was reduced in the CPAP group, but this finding did not reach statistical significance (RR 0.45, 95% CI 0.18 to 1.14; I(2) = 0).Secondary outcomes such as length of hospital stay and adverse effects were only minimally reported.A summary of findings table was constructed using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) principle. The quality of evidence was determined to be very low.

AUTHORS' CONCLUSIONS

Very low-quality evidence from this review suggests that CPAP initiated during the postoperative period might reduce postoperative atelectasis, pneumonia and reintubation, but its effects on mortality, hypoxia or invasive ventilation are uncertain. Evidence is not sufficiently strong to confirm the benefits or harms of CPAP during the postoperative period in those undergoing major abdominal surgery. Most of the included studies did not report on adverse effects attributed to CPAP.New, high-quality research is much needed to evaluate the use of CPAP in preventing mortality and morbidity following major abdominal surgery. With increasing availability of CPAP to our surgical patients and its potential to improve outcomes (possibly in conjunction with intraoperative lung protective ventilation strategies), unanswered questions regarding its efficacy and safety need to be addressed. Any future study must report on the adverse effects of CPAP.

Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial

OBJECTIVE

To determine the long-term (12-year) effects of a conservative nurse-led intervention for postnatal urinary incontinence.

DESIGN

Follow-up of a randomised controlled trial.

SETTING

Community-based intervention in three centres (in the UK and New Zealand).

POPULATION

A cohort of 747 women with urinary incontinence at 3 months after childbirth, of whom 471 (63%) were followed up after 12 years.

METHODS

Women were randomly allocated to active conservative treatment after delivery (pelvic floor muscle training and bladder training), or to a control group receiving standard care.

MAIN OUTCOME MEASURES

Prevalence of urinary incontinence (primary outcome) and faecal incontinence, symptoms and signs of prolapse, and performance of pelvic floor muscle training at 12 years.

RESULTS

The significant improvements relative to controls that had been found in urinary incontinence (60 versus 69%; risk difference, RD, -9.1%; 95% confidence interval, 95% CI, -17.3 to -1.0%) and faecal incontinence (4 versus 11%; RD -6.1%; 95% CI -10.8 to -1.6%) at 1 year did not persist for urinary incontinence (83 versus 80%; RD 2.1%; 95% CI -4.9 to 9.1%) or faecal incontinence (19 versus 15%; RD 4.3%; 95% CI -2.5 to 11.0%) at the 12-year follow up, irrespective of incontinence severity at trial entry. The prevalence of prolapse symptoms or objectively measured pelvic organ prolapse also did not differ between the groups. In the short term the intervention motivated more women to perform pelvic floor muscle training (83 versus 55%), but this fell in both groups by 12 years (52 versus 49%).

CONCLUSIONS

The moderate short-term benefits of a brief nurse-led conservative treatment for postnatal urinary incontinence did not persist. About four-fifths of women with urinary incontinence 3 months after childbirth still had this problem 12 years later.

Low back and neck pain in locomotive engineers exposed to whole-body vibration

The objective of this study was to determine the prevalence and excess risk of low back pain and neck pain in locomotive engineers, and to investigate the relationship of both with whole-body vibration exposure. A cross-sectional survey comparing locomotive engineers with other rail worker referents was conducted. Current vibration levels were measured, cumulative exposures calculated for engineers and referents, and low back and neck pain assessed by a self-completed questionnaire. Median vibration exposure in the z- (vertical) axis was 0.62 m/s(2). Engineers experienced more frequent low back and neck pain, odds ratios (ORs) of 1.77 (95% confidence interval [CI]: 1.19-2.64) and 1.92 (95% CI: 1.22-3.02), respectively. The authors conclude that vibration close to the "action levels" of published standards contribute to low back and neck pain. Vibration levels need to be assessed conservatively and control measures introduced.

Interventions for protecting renal function in the perioperative period

BACKGROUND

Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, N-acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO).

OBJECTIVES

This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period.We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others?

SEARCH METHODS

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards.

SELECTION CRITERIA

We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period.

DATA COLLECTION AND ANALYSIS

We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre-existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality.

MAIN RESULTS

The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit.Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta-analysis on the combined data.Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre-existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97.

AUTHORS' CONCLUSIONS

No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end-stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period.

Weighted vaginal cones for urinary incontinence

BACKGROUND

For a long time pelvic floor muscle training (PFMT) has been the most common form of conservative (non-surgical) treatment for stress urinary incontinence (SUI). Weighted vaginal cones can be used to help women to train their pelvic floor muscles. Cones are inserted into the vagina and the pelvic floor is contracted to prevent them from slipping out.

OBJECTIVES

The objective of this review is to determine the effectiveness of vaginal cones in the management of female urinary stress incontinence (SUI).We wished to test the following comparisons in the management of stress incontinence: 1. vaginal cones versus no treatment; 2. vaginal cones versus other conservative therapies, such as PFMT and electrostimulation; 3. combining vaginal cones and another conservative therapy versus another conservative therapy alone or cones alone; 4. vaginal cones versus non-conservative methods, for example surgery or injectables.Secondary issues which were considered included whether:1. it takes less time to teach women to use cones than it does to teach the pelvic floor exercise; 2. self-taught use is effective;3. the change in weight of the heaviest cone that can be retained is related to the level of improvement;4. subgroups of women for whom cone use may be particularly effective can be identified.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 September 2012), MEDLINE (January 1966 to March 2013), EMBASE (January 1988 to March 2013) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing weighted vaginal cones with alternative treatments or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion and trial quality. Data were extracted by one reviewer and cross-checked by the other. Study authors were contacted for extra information.

MAIN RESULTS

We included 23 trials involving 1806 women, of whom 717 received cones. All of the trials were small, and in many the quality was hard to judge. Outcome measures differed between trials, making the results difficult to combine. Some trials reported high drop-out rates with both cone and comparison treatments. Seven trials were published only as abstracts.Cones were better than no active treatment (rate ratio (RR) for failure to cure incontinence 0.84, 95% confidence interval (CI) 0.76 to 0.94). There was little evidence of difference for a subjective cure between cones and PFMT (RR 1.01, 95% CI 0.91 to 1.13), or between cones and electrostimulation (RR 1.26, 95% CI 0.85 to 1.87), but the confidence intervals were wide. There was not enough evidence to show that cones plus PFMT was different to either cones alone or PFMT alone. Only seven trials used a quality of life measures and no study looked at economic outcomes.Seven of the trials recruited women with symptoms of incontinence, while the others required women with urodynamic stress incontinence, apart from one where the inclusion criteria were uncertain.

AUTHORS' CONCLUSIONS

This review provides some evidence that weighted vaginal cones are better than no active treatment in women with SUI and may be of similar effectiveness to PFMT and electrostimulation. This conclusion must remain tentative until larger, high-quality trials, that use comparable and relevant outcomes, are completed. Cones could be offered as one treatment option, if women find them acceptable.

Traumatic and non-traumatic spinal cord impairment in New Zealand: incidence and characteristics of people admitted to spinal units

This paper estimates the incidence (all ages) of spinal cord neurological impairment (SCI; traumatic and non-traumatic) in New Zealand and describes pre-SCI characteristics and early post-SCI outcomes for participants (16–64 years) in this longitudinal study. Demographic and clinical data on all people admitted to New Zealand's two spinal units (mid-2007 to mid-2009) were included for the estimate of incidence. Participants in this longitudinal study were asked at first interview about pre-SCI socio-demographic, health and behavioural characteristics, and about post-SCI symptoms, general health status (EQ-5D) and disability (WHODAS 12-item). Age-adjusted incidence rates (95% CI) for European, Māori, Pacific and ‘Other’ ethnicities were 29 (24–34), 46 (30–64), 70 (40–100) and 16 (9–22) per million, respectively. Interviews with 118 (73%) participants (16–64 years), occurred 6.5 months post-SCI. Most reported bother with symptoms, and problems with health status and disability. Compared with Europeans, the incidence of SCI is high among Māori and particularly high among Pacific people. Six months after SCI, proximate to discharge from the spinal units, considerable symptomatic, general health and disability burden was borne by people with SCI.

Interventions for treating acute elbow dislocations in adults

BACKGROUND

Dislocation of the elbow joint is a relatively uncommon injury.

OBJECTIVES

To assess the effects of various forms of treatment for acute simple elbow dislocations in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March Week 5 2011), EMBASE (1980 to 2011 Week 14), PEDro (April 2011), CINAHL (April 2011), various trial registers, various conference proceedings and bibliographies of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of conservative and surgical treatment of dislocations of the elbow in adults. Excluded were trials involving dislocations with associated fractures, except for avulsion fractures.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias were independently performed by two review authors. There was no pooling of data.

MAIN RESULTS

Two small randomised controlled trials, involving a total of 80 participants with simple elbow dislocations, were included. Both trials were methodologically flawed and potentially biased.One trial, involving 50 participants, compared early mobilisation at three days post reduction versus cast immobilisation. At one year follow-up, the recovery of range of motion appeared better in the early mobilisation group (e.g. participants with incomplete recovery of extension: 1/24 versus 5/26; risk ratio 0.22, 95% confidence interval 0.03 to 1.72). However, the results were not statistically significant. There were no reports of instability or recurrence. One person in each group had residual pain at one year.The other trial, involving 30 participants, compared surgical repair of the torn ligaments versus conservative treatment (cast immobilisation for two weeks). At final follow-up (mean 27.5 months), there were no statistically significant differences between the two groups in the numbers of patients who considered their injured elbow to be inferior to their non-injured elbow (10/14 versus 7/14; RR 1.43, 95% CI 0.77 to 2.66) or in other patient complaints about their elbow such as weakness, pain or weather-related discomfort. There were no reports of instability or recurrence. There were no statistically significant differences between the two groups in range of motion of the elbow (extension, flexion, pronation, and supination) or grip strength at follow-up. No participants had neurological disturbances of the hand but two surgical group participants had recurrent dislocation of the ulnar nerve (no other details provided). One person in each group had radiologically detected myositis ossificans (bone formation within muscles following injury).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for simple dislocations of the elbow in adults. Although weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment does not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improves long-term function. Future research should focus on questions relating to non-surgical treatment, such as the duration of immobilisation.

Which anticholinergic drug for overactive bladder symptoms in adults

BACKGROUND

Around 16% to 45% of adults have overactive bladder symptoms (urgency with frequency and/or urge incontinence - 'overactive bladder syndrome'). Anticholinergic drugs are common treatments.

OBJECTIVES

To compare the effects of different anticholinergic drugs for overactive bladder symptoms.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 March 2011) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials in adults with overactive bladder symptoms or detrusor overactivity that compared one anticholinergic drug with another, or two doses of the same drug.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook.

MAIN RESULTS

Eighty six trials, 70 parallel and 16 cross-over designs were included (31,249 adults). Most trials were described as double-blind, but were variable in other aspects of quality. Crossover studies did not present data in a way that could be included in the meta-analyses. Twenty nine collected quality of life data (the primary outcome measure) using validated measures, but only fifteen reported useable data.Tolterodine versus oxybutynin: There were no statistically significant differences for quality of life, patient reported cure or improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events with tolterodine (Risk Ratio (RR) 0.52, 95% confidence interval (CI) 0.40 to 0.66, data from eight trials), and less risk of dry mouth (RR 0.65, 95% CI 0.60 to 0.71, data from ten trials).Solifenacin versus tolterodine: There were statistically significant differences for quality of life (standardised mean difference (SMD) -0.12, 95% CI -0.23 to -0.01, data from three trials), patient reported cure/improvement (RR 1.25, 95% CI 1.13 to 1.39, data from two trials), leakage episodes in 24 hours (weighted mean difference (WMD) -0.30, 95% CI -0.53 to -0.08, data from four studies) and urgency episodes in 24 hours (WMD -0.43, 95% CI -0.74 to -0.13, data from four trials), all favouring solifenacin. There was no difference in withdrawals due to adverse events and dry mouth, but after sensitivity analysis the dry mouth (RR 0.69, 95% CI 0.51 to 0.94) was statistically significantly lower with solifenacin when compared to Immediate Release (IR) tolterodine.Fesoterodine versus extended release tolterodine: Three trials contributed to the meta analyses. There were statistically significant differences for quality of life (SMD -0.20, 95% CI -0.27 to -0.14), patient reported cure/improvement (RR 1.11, 95% CI 1.06 to 1.16), leakage episodes (WMD -0.19, 95% CI -0.30 to -0.09), frequency (WMD -0.27, 95% CI -0.47 to -0.06) and urgency episodes (WMD -0.44, 95% CI -0.72 to -0.16) in 24 hours, all favouring fesoterodine, but those taking fesoterodine had higher risk of withdrawal due to adverse events (RR 1.45, 95% CI 1.07 to 1.98) and higher risk of dry mouth (RR 1.80, 95% CI 1.58 to 2.05) at 12 weeks.Different doses of tolterodine: The standard recommended starting dose (2 mg twice daily) was compared with two lower (0.5 mg and 1 mg twice daily), and one higher dose (4 mg twice daily). The effects of 1 mg, 2 mg and 4 mg doses were similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses at two to 12 weeks.Different doses of solifenacin: The standard recommended starting dose of 5 mg once daily was compared to 10 mg: while frequency and urgency were less (better) with 10 mg compared to 5 mg, there was a higher risk of dry mouth with 10 mg solifenacin at four to 12 weeks.Different doses of fesoterodine:The recommended starting dose of 4mg once daily was compared to 8 and 12 mg. The clinical efficacy (patient reported cure, leakage episodes, micturition per 24 hours) of 8 mg was better than 4 mg fesoterodine but with a higher risk of dry mouth with 8 mg.There was no statistically significant difference between 4 and 12 mg in the efficacy but the dry mouth was significantly higher with 12 mg at eight to 12 weeks.Extended versus immediate release preparations of oxybutynin and/or tolterodine: There were no statistically significant differences for cure/improvement, leakage episodes or micturitions in 24 hours, or withdrawals due to adverse events, but there were few data. Overall, extended release preparations had less risk of dry mouth at two to 12 weeks.One extended release preparation versus another: There was less risk of dry mouth with oral extended release tolterodine than oxybutynin (RR 0.75, 95% CI 0.59 to 0.95), but no difference between transdermal oxybutynin and oral extended release tolterodine although some people withdrew due to skin reaction at the transdermal patch site at 12 weeks.

AUTHORS' CONCLUSIONS

Where the prescribing choice is between oral immediate release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. With tolterodine, 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective, with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth.Between solifenacin and immediate release tolterodine, solifenacin might be preferred for better efficacy and less risk of dry mouth. Solifenacin 5 mg once daily is the usual starting dose, this could be increased to 10 mg once daily for better efficacy but with increased risk of dry mouth.Between fesoterodine and extended release tolterodine, fesoterodine might be preferred for superior efficacy but has higher risk of withdrawal due to adverse events and higher risk of dry mouth.There is little or no evidence available about quality of life, costs, or long-term outcome in these studies. There were insufficient data from trials of other anticholinergic drugs to draw any conclusions.

Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress urinary incontinence. It is also sometimes recommended for mixed and, less commonly, urge urinary incontinence. The supervision and content of pelvic floor muscle training programmes are highly variable, and some programmes use additional strategies in an effort to increase adherence or training effects.

OBJECTIVES

To compare the effects of different approaches to pelvic floor muscle training for women with urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 17 May 2011), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials or quasi-randomised trials in women with stress, urge or mixed urinary incontinence (based on symptoms, signs or urodynamics). One arm of the study included pelvic floor muscle training. Another arm was an alternative approach to pelvic floor muscle training, such as a different way of teaching, supervising or performing pelvic floor muscle training.

DATA COLLECTION AND ANALYSIS

We independently assessed trials for eligibility and methodological quality. We extracted then cross-checked data. We resolved disagreements by discussion. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). We subgrouped trials by intervention.

MAIN RESULTS

We screened 574 records for eligibility and included 21 trials in the review. The 21 trials randomised 1490 women and addressed 11 comparisons. These were: differences in training supervision (amount, individual versus group), in approach (one versus another, the effect of an additional component) and the exercise training (type of contraction, frequency of training). In women with stress urinary incontinence, 10% of those who received weekly or twice-weekly group supervision in addition to individual appointments with the therapist did not report improvement post-treatment compared to 43% of the group who had individual appointments only (risk ratio (RR) for no improvement 0.29, 95% confidence interval (CI) 0.15 to 0.55, four trials). Looking at this another way, 90% of those who had combined group and individual supervision reported improvement versus 57% of women receiving individual supervision only. While women receiving the combination of frequent group supervision and individual supervision of pelvic floor muscle training were more likely to report improvement, the confidence interval was wide, and more than half of the 'control' group (the women who did not get the additional weekly or twice-weekly group supervision) reported improvement. This finding, of subjective improvement in both active treatment groups, with more improvement reported by those receiving more health professional contact, was consistent throughout the review.We feel there are several reasons why caution is needed when interpreting the results of the review: there were few data in any comparison; a number of trials were confounded by comparing two arms with multiple differences in the approaches to pelvic floor muscle training; there was a likelihood of a relationship between attention and reporting of more improvement in women who were not blind to treatment allocation; some trials chose interventions that were unlikely to have a muscle training effect; and some trials did not adequately describe their intervention.

AUTHORS' CONCLUSIONS

This review found that the existing evidence was insufficient to make any strong recommendations about the best approach to pelvic floor muscle training. We suggest that women are offered reasonably frequent appointments during the training period, because the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing pelvic floor muscle training with little or no supervision.

Botulinum toxin injections for adults with overactive bladder syndrome

BACKGROUND

Overactive bladder syndrome (OAB) is a common condition with a significant negative impact on quality of life characterised by urgency with or without urge incontinence, frequency and nocturia.  Intravesical botulinum toxin is being increasingly used to treat severe overactive bladder refractory to standard management.  An increasing body of literature is forming that supports this technique as effective, well tolerated, and safe.  This review is a substantial update of the 2007 review of the same title.

OBJECTIVES

The objective was to compare intravesical botulinum toxin with other treatments for neurogenic and idiopathic overactive bladder in adults. The hypothesis to be addressed were whether intravesical injection of botulinum toxin was better than placebo or no treatment; pharmacological and other non-pharmacological interventions; whether higher doses of botulinum toxin were better than lower doses; whether botulinum toxin in combination with other treatments was better than other treatments alone; whether one formulation of botulinum toxin is better than another; and whether one injection technique was better than another.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 23 February 2010). The Register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and handsearching of journals and conference proceedings. Additionally, all reference lists of selected trials and relevant review papers were searched. No limitations were placed on the searches.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for OAB in adults in which at least one management arm involved intravesical injection of botulinum toxin were included. Participants had either neurogenic OAB or idiopathic OAB with or without stress incontinence. Comparison interventions could include no intervention, placebo, lifestyle modification, bladder retraining, pharmacological treatments, surgery, bladder instillation techniques, neuromodulation, and different types, doses, and injection techniques of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Binary outcomes were presented as relative risk and continuous outcomes by mean differences. Little data could be synthesised across studies due to differing study designs and outcome measures. Where applicable standard deviations were calculated from P values according to the formula described in section 7.7.3.3 of the Cochrane Handbook of Systematic Reviews of Interventions. Data were tabulated where possible with results taken from trial reports where this was not possible. Where multiple publications were found, the reports were treated as a single source of data.

MAIN RESULTS

Nineteen studies were identified that met the inclusion criteria.  Most patients in the studies had neurogenic OAB, but some included patients with idiopathic OAB.  All studies demonstrated superiority of botulinum toxin to placebo.  Lower doses of botulinum toxin (100 to 150 U) appeared to have beneficial effects, but larger doses (300 U) may have been more effective and longer lasting, but with more side effects.  Suburothelial injection had comparable efficacy to intradetrusor injection. The effect of botulinum toxin may last for a number of months and is dependent upon dose and type of toxin used. Patients receiving repeated doses do not seem to become refractory to botulinum toxin. Botulinum toxin appeared to have beneficial effects in OAB that quantitatively exceeded the effects of intravesical resiniferatoxin. Intravesical botulinum toxin appeared to be reasonably safe; however, one study was halted due to a perceived unacceptable rate of urinary retention. 

AUTHORS' CONCLUSIONS

Intravesical botulinum toxin appears to be an effective therapy for refractory OAB symptoms, but as yet little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. Further robust data are required on long term outcomes, safety, and optimal dose of botulinum toxin for OAB.

Predicted versus absolute values in the application of exhaled nitric oxide measurements

BACKGROUND

Constitutional factors such as age, sex and height, and acquired factors such as atopy and smoking, influence exhaled nitric oxide (F(E)NO) levels. The utility of predicted values based on reference equations which account for these factors has not been evaluated.

AIM

To compare the performance characteristics of absolute versus % predicted values for F(E)NO as predictors of diagnosed asthma and steroid response.

METHODS

We compared the sensitivities, specificities and likelihood ratios using F(E)NO (% predicted) with absolute values for F(E)NO (ppb) in 52 steroid-naive subjects with non-specific respiratory symptoms. The reference equations of Olin et al. (Chest, 2007) and Dressel et al. (Resp. Med., 2008) were used to derive predicted values. Receiver operating curve analyses were performed and the areas under the curve (AUC) were calculated for two outcomes: diagnosed asthma (yes/no), and steroid response after fluticasone for 4 weeks (defined as ≥ 12% increase in FEV(1); increase in mean morning PEF ≥ 15%; reduction in symptoms ≥ 1 point; increase in PC(20)AMP of ≥ 2 doubling doses).

RESULTS

The AUCs for diagnosed asthma were: F(E)NO (absolute) 0.770; F(E)NO (% pred.): 0.758 (Olin) and 0.775 (Dressel) (NS). The AUCs for F(E)NO (abs.) and F(E)NO (% pred.) with respect to the four indices of steroid response were likewise not significantly different.

CONCLUSION

Correcting F(E)NO for combinations of age, sex, height, smoking and atopy using reference equations did not enhance the performance characteristics of F(E)NO as a predictor of either the diagnosis of asthma or steroid responsiveness in patients with chronic airways-related symptoms.

Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is an effective treatment for stress urinary incontinence in women. Whilst most of the PFMT trials have been done in women with stress urinary incontinence, there is also some trial evidence that PFMT is effective for urgency urinary incontinence and mixed urinary incontinence. Feedback or biofeedback are common adjuncts used along with PFMT to help teach a voluntary pelvic floor muscle contraction or to improve training performance.

OBJECTIVES

To determine whether feedback or biofeedback adds further benefit to PFMT for women with urinary incontinence.To compare the effectiveness of different forms of feedback or biofeedback.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 13 May 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in women with stress, urgency or mixed urinary incontinence (based on symptoms, signs or urodynamics). At least two arms of the trials included PFMT. In addition, at least one arm included verbal feedback or device-mediated biofeedback.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for eligibility and risk of bias. Data were extracted by two reviewers and cross-checked. Disagreements were resolved by discussion or the opinion of a third reviewer. Data analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Intervention (version 5.1.0). Analysis within subgroups was based on whether there was a difference in PFMT between the two arms that had been compared.

MAIN RESULTS

Twenty four trials involving 1583 women met the inclusion criteria; 17 trials contributed data to analysis for one of the primary outcomes. All trials contributed data to one or more of the secondary outcomes. Women who received biofeedback were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received PFMT alone (risk ratio 0.75 , 95% confidence interval 0.66 to 0.86). However, it was common for women in the biofeedback arms to have more contact with the health professional than those in the non-biofeedback arms. Many trials were at moderate to high risk of bias, based on trial reports. There was much variety in the regimens proposed for adding feedback or biofeedback to PFMT alone, and it was often not clear what the actual intervention comprised or what the purpose of the intervention was.

AUTHORS' CONCLUSIONS

Feedback or biofeedback may provide benefit in addition to pelvic floor muscle training in women with urinary incontinence. However, further research is needed to differentiate whether it is the feedback or biofeedback that causes the beneficial effect or some other difference between the trial arms (such as more contact with health professionals).

Ascertainment of occupational histories in the working population: the occupational history calendar approach

BACKGROUND

self-reported occupational histories are an important means for collecting historical data in epidemiological studies. An occupational history calendar (OHC) has been developed for use alongside a national occupational hazard surveillance tool. This study presents the systematic development of the OHC and compares work histories collected via this calendar to those collected via a traditional questionnaire.

METHODS

the paper describes the systematic development of an OHC for use in the general working population. A comparison of data quality and recall was undertaken in 51 participants where both tools were administered.

RESULTS

the OHC enhanced job recall compared with the traditional questionnaire. Good agreement in the data captured by both tools was observed, with the exception of hazard exposures.

CONCLUSIONS

a calendar approach is suitable for collecting occupational histories from the general working population. Despite enhancing job recall the OHC approach has some shortcomings outweighing this advantage in large-scale population surveillance.

A longitudinal study of the life histories of people with spinal cord injury

BACKGROUND

Approximately 70-80 New Zealanders have spinal cord impairment (SCI) due to injury (2/3) or disease (1/3) each year. They had been socialized as non-disabled people. Following paralysis, interrelationships between body, self and society change. Little is known of the impact of these changes on life histories, life chances and life choices of people with SCI. This has negative implications for the design of rehabilitation and disability support services in New Zealand. Furthermore, the trajectory of disability is affected by previous socioeconomic conditions. How specific supports following SCI (eg, rehabilitation and compensation funded by the Accident Compensation Corporation; ACC) can change this trajectory is unknown.

OBJECTIVES

To explore the interrelationships of body, self and society for people with SCI and how these have shaped life chances, life choices and subjectivity. To investigate how entitlement to rehabilitation and compensation through ACC affects socioeconomic and health outcomes.

SETTING

New Zealand.

DESIGN

A prospective cohort study; mixed methods.

PARTICIPANTS

112 people with SCI admitted for the first time to one of New Zealand's two spinal units without serious cognitive injury.

DATA

Structured interviews with all participants (n=112); qualitative interviews with a selected subgroup (n=20); clinical data collected at the time of admission. Exposures include: demographics, comorbidity, previous health and socioeconomic status, SCI resulting from illness or injury, income support, health and social services.

OUTCOME MEASURES

Socioeconomic status, health, participation and life satisfaction.

ANALYSIS

Descriptive statistics; differences tested by paired t tests or McNemar tests; multiple regression and mixed models. Qualitative analysis will be interpretive.

Long term performance characteristics of an electrochemical nitric oxide analyser

BACKGROUND

The NIOX MINO(®) is a nitric oxide (FE(NO)) analyser based on electrochemical technology. It includes a replaceable sensor. Quality control procedures are recommended, but regular calibration is not possible. We aimed to evaluate the performance characteristics of the NIOX MINO(®) to identify if reproducibility changed over time, or with different sensors. Also, there are reports that reproducibility of FE(NO) may be reduced in patients with high FE(NO): our secondary aim was to address this issue.

METHODS

Reproducibility in 24 separate sensor-analyser units was calculated on three occasions over two months in 17 patients. These included 9 patients whose FE(NO) was high (mean 80 ppb) and 8 in whom FE(NO) was low (mean 16 ppb).

RESULTS

One device failed quality control testing. For the remaining 23 sensor-analyser combinations, the mean coefficient of variation was 4.0% (range 1.2-7.2%) at baseline, 3.6% (range 2.0-7.0) at one month, and 3.6% (range 1.6-7.6%) at two months. The 95% C.I. for the mean limits of agreement for FE(NO) was ± 4.2 ppb (range 0.9-9.6 ppb), ± 3.8 ppb (range 1.6-6.9 ppb) and ± 3.2 ppb (range 1.2-6.8 ppb) respectively (NS). The limits of agreement exceeded the manufacturer's specifications (± 5 ppb) in 0 devices at baseline, 3 (13%) at one month, and 5 (22%) at two months.

CONCLUSIONS

Reproducibility of FE(NO) using the NIOX MINO(®) was within clinically acceptable limits (± 10 ppb) and was generally stable. However, with time, a proportion of individual sensor-analyser combinations yielded variability outside the manufacturer's specifications.

Obstacles to researching the researchers: a case study of the ethical challenges of undertaking methodological research investigating the reporting of randomised controlled trials

BACKGROUND

Recent cohort studies of randomised controlled trials have provided evidence of within-study selective reporting bias; where statistically significant outcomes are more likely to be more completely reported compared to non-significant outcomes. Bias resulting from selective reporting can impact on meta-analyses, influencing the conclusions of systematic reviews, and in turn, evidence based clinical practice guidelines.In 2006 we received funding to investigate if there was evidence of within-study selective reporting in a cohort of RCTs submitted to New Zealand Regional Ethics Committees in 1998/99. This research involved accessing ethics applications, their amendments and annual reports, and comparing these with corresponding publications. We did not plan to obtain informed consent from trialists to view their ethics applications for practical and scientific reasons. In November 2006 we sought ethical approval to undertake the research from our institutional ethics committee. The Committee declined our application on the grounds that we were not obtaining informed consent from the trialists to view their ethics application. This initiated a seventeen month process to obtain ethical approval. This publication outlines what we planned to do, the issues we encountered, discusses the legal and ethical issues, and presents some potential solutions.

DISCUSSION AND CONCLUSION

Methodological research such as this has the potential for public benefit and there is little or no harm for the participants (trialists) in undertaking it. Further, in New Zealand, there is freedom of information legislation, which in this circumstance, unambiguously provided rights of access and use of the information in the ethics applications. The decision of our institutional ethics committee defeated this right and did not recognise the nature of this observational research. Methodological research, such as this, can be used to develop processes to improve quality in research reporting. Recognition of the potential benefit of this research in the broader research community, and those who sit on ethics committees, is perhaps needed. In addition, changes to the ethical review process which involve separation between those who review proposals to undertake methodological research using ethics applications, and those with responsibility for reviewing ethics applications for trials, should be considered. Finally, we contend that the research community could benefit from quality improvement approaches used in allied sectors.

Outcomes using exhaled nitric oxide measurements as an adjunct to primary care asthma management

BACKGROUND

Exhaled nitric oxide (FENO) measurements may help to highlight when inhaled corticosteroid (ICS) therapy should or should not be adjusted in asthma. This is often difficult to judge. Our aim was to evaluate a decision-support algorithm incorporating FENO measurements in a nurse-led asthma clinic.

METHODS

Asthma management was guided by an algorithm based on high (>45ppb), intermediate (30-45ppb), or low (<30ppb) FENO levels and asthma control status. This provided for one of eight possible treatment options, including diagnosis review and ICS dose adjustment.

RESULTS

Well controlled asthma increased from 41% at visit 1 to 68% at visit 5 (p=0.001). The mean fluticasone dose decreased from 312 mcg/day at visit 2 to 211mcg/day at visit 5 (p=0.022). There was a high level of protocol deviations (25%), often related to concerns about reducing the ICS dose. The % fall in FENO associated with a change in asthma status from poor control to good control was 35%.

CONCLUSION

An FENO-based algorithm provided for a reduction in ICS doses without compromising asthma control. However, the results may have been influenced by the education and support which patients received. Reluctance to reduce ICS dose was an issue which may have influenced the overall results.

TRIAL REGISTRATION

Australian Clinical Trials Registry # 012605000354684.

The impact of body mass index on semen parameters and reproductive hormones in human males: a systematic review with meta-analysis

BACKGROUND

It has been suggested that body mass index (BMI), especially obesity, is associated with subfertility in men. Semen parameters are central to male fertility and reproductive hormones also play a role in spermatogenesis. This review aimed to investigate the association of BMI with semen parameters and reproductive hormones in men of reproductive age.

METHODS

MEDLINE, EMBASE, Biological Abstracts, PsycINFO and CINAHL databases and references from relevant articles were searched in January and February 2009. Outcomes included for semen parameters were sperm concentration, total sperm count, semen volume, motility and morphology. Reproductive hormones included were testosterone, free testosterone, estradiol, FSH, LH, inhibin B and sex hormone binding globulin (SHBG). A meta-analysis was conducted to investigate sperm concentration and total sperm count.

RESULTS

In total, 31 studies were included. Five studies were suitable for pooling and the meta-analysis found no evidence for a relationship between BMI and sperm concentration or total sperm count. Overall review of all studies similarly revealed little evidence for a relationship with semen parameters and increased BMI. There was strong evidence of a negative relationship for testosterone, SHBG and free testosterone with increased BMI.

CONCLUSIONS

This systematic review with meta-analysis has not found evidence of an association between increased BMI and semen parameters. The main limitation of this review is that data from most studies could not be aggregated for meta-analysis. Population-based studies with larger sample sizes and longitudinal studies are required.

Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults

BACKGROUND

The neural control of storage and voiding of urine is complex and dysfunction can be difficult to treat. One treatment for people with refractory symptoms is continuous electrical nerve stimulation of the sacral nerve roots using implanted electrodes and an implanted pulse generator.

OBJECTIVES

To determine the effects of implantable electrical stimulation devices in the treatment of urine storage and voiding problems.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 10 February 2009), CENTRAL (The Cochrane Library 2008, Issue 1), MEDLINE (January 1980 to March 2008), EMBASE (January 1980 to March 2008), CINAHL (January 1982 to March 2008) and the reference lists of relevant articles.

SELECTION CRITERIA

Trials that tested implanted electronic stimulators connected to electrodes attached to the nerves and providing continuous electrical stimulation for neuromodulation.

DATA COLLECTION AND ANALYSIS

Both authors selected studies, assessed quality, and extracted data.

MAIN RESULTS

Eight reports of randomised studies that evaluated implants which provided continuous stimulation were included. It was unclear whether some reports included patients who also appeared in other reports, so no data were pooled. In spite of this, it seems clear that continuous stimulation offers benefits for carefully selected people with overactive bladder syndrome and for those with urinary retention but no structural obstruction.Many of the implants did not work and many required revision operations. Many questions remain about patient selection and the best way to use these devices.

AUTHORS' CONCLUSIONS

In spite of methodological problems, it would appear that some people benefit from implants which provide continuous nerve stimulation. More research is needed on the best way to improve patient selection, carry out the implant, and to find why so many fail. The effectiveness of implants should be tested against other interventions, particularly in people with an overactive bladder.

Mortality in employees at a New Zealand agrochemical manufacturing site

Background Previous studies at the Dow AgroSciences (Formerly Ivon Watkins-Dow) plant in New Plymouth, New Zealand, had raised concerns about the cancer risk in a subset of workers at the site with potential exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin. As the plant had been involved in the synthesis and formulation of a wide range of agrochemicals and their feedstocks, we examined the mortality risk for all workers at the site.

Aims To quantify the mortality hazards arising from employment at the Dow AgroSciences agrochemical production site in New Plymouth, New Zealand.

Methods Workers employed between 1 January 1969 and 1 October 2003 were followed up to the end of 2004. Standardized mortality ratios (SMRs) were calculated using national mortality rates by employment duration, sex, period of hire and latency.

Results A total of 1754 employees were followed during the study period and 247 deaths were observed. The all causes and all cancers SMRs were 0.97 (95% CI 0.85–1.10) and 1.01 (95% CI 0.80–1.27), respectively. Mortality due to all causes was higher for short-term workers (SMR 1.23, 95% CI 0.91–1.62) than long-term workers (SMR 0.92, 95% CI 0.80–1.06) and women had lower death rates than men. Analyses by latency and period of hire did not show any patterns consistent with an adverse impact of occupational exposures.

Conclusions The mortality experience of workers at the site was similar to the rest of New Zealand.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About a third of women have urinary incontinence and up to a tenth have faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and treatment of incontinence.

OBJECTIVES

To determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 24 April 2008) and the references of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trials needed to include pelvic floor muscle training (PFMT). Another arm was either no pelvic floor muscle training or usual antenatal or postnatal care. The pelvic floor muscle training programmes were divided into either: intensive; or unspecified if training elements were lacking or information was not provided. Reasons for classifying as intensive included one to one instruction, checking for correct contraction, continued supervision of training, or choice of an exercise programme with sufficient exercise dose to strengthen muscle.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for eligibility and methodological quality. Data were extracted then cross checked. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Three different populations of women were considered separately: women dry at randomisation (prevention); women wet at randomisation (treatment); and a population-based approach in women who might be one or the other (prevention or treatment). Trials were further divided into: those which started during pregnancy (antenatal); and after delivery (postnatal).

MAIN RESULTS

Sixteen trials met the inclusion criteria. Fifteen studies involving 6181 women (3040 PFMT, 3141 controls) contributed to the analysis. Based on the trial reports, four trials appeared to be at low risk of bias, two at low to moderate risk, and the remainder at moderate risk of bias.Pregnant women without prior urinary incontinence who were randomised to intensive antenatal PFMT were less likely than women randomised to no PFMT or usual antenatal care to report urinary incontinence in late pregnancy (about 56% less; RR 0.44, 95% CI 0.30 to 0.65) and up to six months postpartum (about 30% less; RR 0.71, 95% CI 0.52 to 0.97).Postnatal women with persistent urinary incontinence three months after delivery and who received PFMT were less likely than women who did not receive treatment or received usual postnatal care (about 20% less; RR 0.79, 95% CI 0.70 to 0.90) to report urinary incontinence 12 months after delivery. It seemed that the more intensive the programme the greater the treatment effect. Faecal incontinence was also reduced at 12 months after delivery: women receiving PFMT were about half as likely to report faecal incontinence (RR 0.52, 95% CI 0.31 to 0.87).Based on the trial data to date, the extent to which population-based approaches to PFMT are effective is less clear (that is, offering advice on PFMT to all pregnant or postpartum women whether they have incontinence symptoms or not). It is possible that population-based approaches might be effective when the intervention is intensive enough.There was not enough evidence about long-term effects for either urinary or faecal incontinence.

AUTHORS' CONCLUSIONS

There is some evidence that PFMT in women having their first baby can prevent urinary incontinence in late pregnancy and postpartum. In common with older women with stress incontinence, there is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence. It is possible that the effects of PFMT might be greater with targeted rather than population-based approaches and in certain groups of women (for example primiparous women; women who had bladder neck hypermobility in early pregnancy, a large baby, or a forceps delivery). These and other uncertainties, particularly long-term effectiveness, require further testing.

Interventions for protecting renal function in the perioperative period

BACKGROUND

A number of methods have been used to try to protect kidney function in patients undergoing surgery. These include the administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors and hydration fluids.

OBJECTIVES

For this review, we selected randomized controlled trials which employed different methods to protect renal function during the perioperative period. In examining these trials, we looked at outcomes that included renal failure and mortality as well as changes in renal function tests, such as urine output, creatinine clearance, free water clearance, fractional excretion of sodium and renal plasma flow.

SEARCH STRATEGY

We searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to June, 2007), and EMBASE (1988 to June, 2007); and handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery).

SELECTION CRITERIA

We selected all randomized controlled trials in adults undergoing surgery where a treatment measure was used for the purpose of renal protection in the perioperative period.

DATA COLLECTION AND ANALYSIS

We selected 53 studies for inclusion in this review. As well as data analysis from all the studies, we performed subgroup analysis for type of intervention, type of surgical procedure, and pre-existing renal dysfunction. We undertook sensitivity analysis on studies with high and moderately good methodological quality.

MAIN RESULTS

The review included data from 53 studies, comprising a total of 2327 participants. Of these, 1293 received some form of treatment and 1034 acted as controls. The interventions mostly consisted of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, or selected hydration fluids. The results indicated that certain interventions showed minimal benefits. All the results suffered from significant heterogeneity. Hence we cannot draw conclusions about the effectiveness of these interventions in protecting patients' kidneys during surgery.

AUTHORS' CONCLUSIONS

There is no reliable evidence from the available literature to suggest that interventions during surgery can protect the kidneys from damage. There is a need for more studies with high methodological quality. One particular area for further study may be patients with pre-existing renal dysfunction undergoing surgery.

Postoperative anemia and quality of life after primary hip arthroplasty in patients over 65 years old

BACKGROUND

It is uncertain whether anemia in elderly patients after primary hip arthroplasty has an effect on their quality of life.

METHODS

We conducted a prospective observational study over 3 mo to investigate the association between discharge hemoglobin levels and subjective experience of quality of life at 2 mo postoperatively in patients aged over 65 yr who were scheduled for primary hip arthroplasty. Quality of life was measured preoperatively and at 2 mo postoperatively using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale. Pearson correlation coefficients between change in SF-36 and FACT-Anemia subscale scores (from preoperatively to 2 mo postoperatively) and hemoglobin on Day 8 were calculated.

RESULTS

Eighty-seven patients were included in the study. Data were available at 2 mo postoperatively from 79 of these patients. The correlation between Day 8 postoperative hemoglobin and change in SF-36 was 0.49 (P < 0.0005) and change in FACT-Anemia subscale score was 0.46 (P = < 0.0005). The correlation was not significantly changed after adjusting for advancing age, presence of significant cardiovascular disease, or whether the patient was transfused.

CONCLUSIONS

We found a positive correlation between hemoglobin levels on discharge and change in quality of life scores from preoperatively to 2 mo postoperatively in patients over 65 yr old after primary hip arthroplasty.

Serial exhaled nitric oxide measurements in the assessment of laboratory animal allergy

BACKGROUND

Laboratory animal allergy (LAA) may cause eosinophilic airway inflammation, for which exhaled nitric oxide (FE(NO)) measurements are sensitive and specific. Our objective was to assess whether serial FE(NO) measurements might detect exposure-related inflammation in laboratory animal workers. METHODS. Fifty laboratory animal workers participated. Measurements of FE(NO) and spirometry were obtained at baseline (Friday) and twice-daily following a weekend with no animal contact.

RESULTS

Eleven of 50 subjects had work-related symptoms, and 2 of 11 had positive serology for LAA. Baseline FE(NO) was high (> 150 ppb) in the two seropositive subjects and increased progressively during the working week in one subject, confirming exposure-driven airway inflammation. In seronegative subjects, mean FE(NO) levels were 19.8 (standard deviation [SD], 20.1) and 21.7 (SD, 20.8) in the symptomatic and nonsymptomatic groups, respectively, with no significant changes in FE(NO) over time.

CONCLUSION

Serial FE(NO) measurements may provide complementary information in the assessment of possible occupational sensitisation. The sensitivity and specificity of this approach to diagnosing occupational asthma requires further evaluation.

Return to continence after radical retropubic prostatectomy: a randomized trial of verbal and written instructions versus therapist-directed pelvic floor muscle therapy

OBJECTIVES

To test the effectiveness of weekly postoperative pelvic floor muscle training (PFMT) versus supportive telephone contact by a urology nurse for men at 4 weeks after radical prostatectomy.

METHODS

This was a randomized controlled trial in three Canadian centers. At 4 weeks after surgery, standardized verbal and written instruction about PFMT was provided to all subjects. Randomization occurred after initial instruction. Continence was defined as 8 g or less of urine loss on a 24-hour pad test. Primary outcome was grams of urine loss on pad test; secondary outcomes were International Prostate Symptom Score (IPSS), Incontinence Impact Questionnaire (IIQ-7) score, cost, and perception of urine loss as a problem. Data were obtained at baseline (preoperatively) and at weeks 4, 8, 12, 16, and 28 and 1 year after surgery.

RESULTS

A total of 216 men were enrolled; 11 were dry or withdrew at 4 weeks. Ninety-nine were randomized to the control group and 106 to the treatment group. There were no group differences at baseline for prostate-specific antigen level (mean [standard deviation] 8.4 [10.4] ng/mL; 7.6 [4.6] ng/mL), Gleason score (6.3 [0.86]), IPSS, IIQ-7 score, pad test, or voiding diary. At 8 weeks 23% of the control group and 20% of the treatment group were continent; at 12 weeks, 28% and 32%; 16 weeks, 40% and 44%; 28 weeks, 50% and 47%; and at 52 weeks, 64% and 60%, respectively. There were no significant differences between groups at any time point for the outcome variables.

CONCLUSIONS

Verbal instruction and written information with telephone support seemed to be as effective as intensive PFMT. Less-intense therapy may be more cost-effective.

Long-term functional outcome and performance status after intensive care unit re-admission: a prospective survey

BACKGROUND

Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission.

METHODS

With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2-3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome.

RESULTS

Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2-3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease.

CONCLUSIONS

Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2-3 yr had by then made a good functional recovery and were independent.

Botulinum toxin injections for adults with overactive bladder syndrome

BACKGROUND

Overactive bladder syndrome is a common condition with a significant negative impact on quality of life. Intravesical injection of botulinum toxin is increasingly used as an intervention for refractory overactive bladder, with a considerable body of case reports and series in the literature suggesting beneficial effects.

OBJECTIVES

The objective was to compare intravesical botulinum toxin injection with other treatments for neurogenic and idiopathic overactive bladder in adults. The hypotheses addressed were whether intravesical injection of botulinum toxin was better: than placebo or no treatment, pharmacological and other non-pharmacological interventions, whether higher doses of botulinum toxin were better than lower doses, whether botulinum toxin in combination with other treatments was better than other treatments alone, whether one formulation of botulinum toxin is better than another, and whether one injection technique was better than another.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 22 November 2005). The register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and handsearching of journals and conference proceedings. Additionally, all reference lists of selected trials were searched. No limitations were placed on the searches.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for overactive bladder syndrome in adults in which at least one management arm involved intravesical injection of botulinum toxin were included. Participants had either neurogenic or idiopathic overactive bladder with or without stress incontinence. Comparison interventions could include no intervention; placebo; lifestyle modification; bladder retraining; pharmacological treatments; surgery; bladder instillation techniques; neuromodulation; and different types, doses, and injection techniques of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Binary outcomes were presented as relative risk and continuous outcomes by mean differences. No data could be synthesised across studies due to differing designs and outcome measures. Data were tabulated where possible with results taken from trial reports where this was not possible. Where multiple publications were found, the reports were treated as a single source of data.

MAIN RESULTS

Eight studies met the inclusion criteria. Results varied between studies. For the most part, studies reported superiority of botulinum toxin A to placebo in such outcomes as incontinence episodes, bladder capacity, maximum detrusor pressure, and quality of life. Low doses of botulinum toxin (100U to150U) appeared to have beneficial effects, but higher doses (300U) may have been more effective. Botulinum toxin appeared to have beneficial effects in overactive bladder that quantitatively exceeded the effects of intravesical resiniferatoxin.

AUTHORS' CONCLUSIONS

Intravesical botulinum toxin shows promise as a therapy for overactive bladder symptoms, but as yet too little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. Practitioners should be aware that at present there is little more than anecdotal evidence, in the form of case reports to support the efficacy of intravesical botulinum toxin; there is not much in the way of substantial, robust safety data. Furthermore, the optimal dose of botulinum toxin for efficacy and safety has not yet been demonstrated.

Chemical exposure among NZ farmers

The objectives were to describe chemical use among farmers; to develop an exposure intensity score for three chemicals of interest: organophosphates (OPs), glyphosate (GP), and phenoxy herbicides (PHs). This was a cross-sectional study of a stratified random sample of farmers. Demographic, health and chemical use information were collected via questionnaire and an exposure level score developed. Within a sample of 586 farmers, 16 - 54% applied one or more of the chemicals. A high proportion of pastoral farmers used all the chemical types with 65% applying GP, 29% OPs and 19% PHs. Mean exposure scores were higher among women OP users, younger PH users, and arable farmers using PHs. This pesticide exposure score based on self-reported work practices among farmers can give an estimate of comparative annual exposure level. It can be used in analytical epidemiological studies and allows the identification of priority areas for intervention.

Associations between respiratory symptoms, lung function and gastro-oesophageal reflux symptoms in a population-based birth cohort

BACKGROUND

Several studies have reported an association between asthma and gastro-oesophageal reflux, but it is unclear which condition develops first. The role of obesity in mediating this association is also unclear. We explored the associations between respiratory symptoms, lung function, and gastro-oesophageal reflux symptoms in a birth cohort of approximately 1000 individuals.

METHODS

Information on respiratory symptoms, asthma, atopy, lung function and airway responsiveness was obtained at multiple assessments from childhood to adulthood in an unselected birth cohort of 1037 individuals followed to age 26. Symptoms of gastro-oesophageal reflux and irritable bowel syndrome were recorded at age 26.

RESULTS

Heartburn and acid regurgitation symptoms that were at least "moderately bothersome" at age 26 were significantly associated with asthma (odds ratio = 3.2; 95% confidence interval = 1.6-6.4), wheeze (OR = 3.5; 95% CI = 1.7-7.2), and nocturnal cough (OR = 4.3; 95% CI = 2.1-8.7) independently of body mass index. In women reflux symptoms were also associated with airflow obstruction and a bronchodilator response to salbutamol. Persistent wheezing since childhood, persistence of asthma since teenage years, and airway hyperresponsiveness since age 11 were associated with a significantly increased risk of heartburn and acid regurgitation at age 26. There was no association between irritable bowel syndrome and respiratory symptoms.

CONCLUSION

Reflux symptoms are associated with respiratory symptoms in young adults independently of body mass index. The mechanism of these associations remains unclear.

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with stress urinary incontinence, with the presumed advantages over traditional Burch colposuspension of avoiding major incisions, shorter hospital stay, and quicker return to normal activities. A variety of approaches and methods are used.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 21 September 2005). Additional trials were sought from other sources such as reference lists, reviews and researchers and authors were contacted for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery in at least one arm of the study.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by two of the reviewers and cross checked by another. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

Twenty-one eligible trials were identified. Nine involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures in the short and medium term follow-up, there was some evidence of poorer results of laparoscopic colposuspension, within 18 months, on objective outcomes. Two poor quality trials reported conflicting long term results (after five years) for this comparison. No significant differences were observed for post-operative urgency, voiding dysfunction or de novo detrusor overactivity. Trends were shown towards a lower perioperative complication rate, longer operating time, less intraoperative blood loss, less postoperative pain, shorter hospital stay, quicker return to normal activities, and shorter duration of catheterisation for laparoscopic compared with open colposuspension. Benefits did not come without a price, as laparoscopic colposuspension in the short term is more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. Overall there were no significant differences in the reported subjective cure rates of the two procedures, however vaginal sling procedures did have significantly higher objective cure rates at 18 months. No significant differences were observed for post-operative voiding dysfunction, de novo detrusor activity and perioperative complications. Laparoscopic colposuspension has a significantly longer operation time, longer hospital stay and slower return to normal activities when compared to the sling procedures. Significantly higher subjective and objective (dry on 'ultrashort' pad test) one year cure rates were found for women randomised to two paravaginal sutures compared with one suture in a single trial (89% versus 65% and 83% versus 58% respectively). Two small studies compared sutures with mesh and staples for laparoscopic colposuspension and the comparisons, although showing a trend towards favouring the sutures, were not significant. One study compared transperitoneal with extraperitoneal access for laparoscopic colposuspension but it was also small and of poor quality.

AUTHORS' CONCLUSIONS

The long-term performance of laparoscopic colposuspension remains uncertain. Currently available evidence suggests that it may be as good as open colposuspension at two years post surgery. Like other laparoscopically performed operations, patients having laparoscopic colposuspension recovered quicker, but the operation itself took longer to perform. However, the newer vaginal sling procedures appear to offer even greater benefits of minimal access surgery and better objective outcomes in the short-term. If laparoscopic colposuspension is performed, two paravaginal sutures appear to be more effective than one. The place of laparoscopic colposuspension in clinical practice should become clearer when ongoing trials are reported and when there are more data available describing long-term cure results.

A randomised clinical trial to investigate bond failure rates using a self-etching primer

This clinical trial evaluated, over a 12-month period, the performance of brackets bonded to teeth etched and primed with Transbond Plus Self-Etching Primer (SEP) when compared with a conventional separate two-step etch and primer system. Thirty-nine randomly selected patients requiring fixed appliance therapy were entered into the study. Random allocation of each etching system, along with a 'split-mouth cross-quadrant' design was used. A total of 661 brackets were placed by two operators. The failure and survival rates of the brackets were determined for age and gender of the patients, each etching system, operator, mode of failure, tooth position in the dental arch, and number of manipulations prior to curing the adhesive. Statistical analysis showed that SEP had a significantly higher bond failure rate (11.2 per cent) than the conventional etch and primer system (3.9 per cent) at the P = 0.001 level. Cox's proportional hazards regression showed the conventional etch and primer system to have a 60 per cent reduced chance of bracket failure over a 12-month observation period, while males had a 2.4 times increased risk compared with females. The predominant mode of failure was at the composite enamel interface for the SEP, while for the conventional etch and primer system, it was within the composite adhesive. No statistically significant differences were found for the failure rate with respect to the age of the patient, operator, tooth location, or the number of manipulations of the bracket. This in vivo study showed that brackets bonded using SEP had an increased clinical bond failure rate compared with the conventional, separate, etch and prime system.