Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework

BACKGROUND

Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials.

METHODS

An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials.

RESULTS

A randomised trial can usefully be classified as 'health equity relevant' if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as 'health equity relevant' may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies.

CONCLUSION

The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.

National Institutes of Health Research Plan on Rehabilitation: NIH Medical Rehabilitation Coordinating Committee

One in five Americans experiences disability that affects their daily function because of impairments in mobility, cognitive function, sensory impairment, or communication impairment. The need for rehabilitation strategies to optimize function and reduce disability is a clear priority for research to address this public health challenge. The National Institutes of Health (NIH) recently published a Research Plan on Rehabilitation that provides a set of priorities to guide the field over the next 5 years. The plan was developed with input from multiple Institutes and Centers within the NIH, the National Advisory Board for Medical Rehabilitation Research, and the public. This article provides an overview of the need for this research plan, an outline of its development, and a listing of six priority areas for research. The NIH is committed to working with all stakeholder communities engaged in rehabilitation research to track progress made on these priorities and to work to advance the science of medical rehabilitation.This article is being published almost simultaneously in the following six journals: American Journal of Occupational Therapy, American Journal of Physical Medicine and Rehabilitation, Archives of Physical Medicine and Rehabilitation, Neurorehabilitation and Neural Repair, Physical Therapy, and Rehabilitation Psychology. Citation information is as follows: NIH Medical Rehabilitation Coordinating Committee. Am J Phys Med Rehabil. 2017;97(4):404-407.

Protocol for the development of a CONSORT-equity guideline to improve reporting of health equity in randomized trials

BACKGROUND

Health equity concerns the absence of avoidable and unfair differences in health. Randomized controlled trials (RCTs) can provide evidence about the impact of an intervention on health equity for specific disadvantaged populations or in general populations; this is important for equity-focused decision-making. Previous work has identified a lack of adequate reporting guidelines for assessing health equity in RCTs. The objective of this study is to develop guidelines to improve the reporting of health equity considerations in RCTs, as an extension of the Consolidated Standards of Reporting Trials (CONSORT).

METHODS/DESIGN

A six-phase study using integrated knowledge translation governed by a study executive and advisory board will assemble empirical evidence to inform the CONSORT-equity extension. To create the guideline, the following steps are proposed: (1) develop a conceptual framework for identifying "equity-relevant trials," (2) assess empirical evidence regarding reporting of equity-relevant trials, (3) consult with global methods and content experts on how to improve reporting of health equity in RCTs, (4) collect broad feedback and prioritize items needed to improve reporting of health equity in RCTs, (5) establish consensus on the CONSORT-equity extension: the guideline for equity-relevant trials, and (6) broadly disseminate and implement the CONSORT-equity extension.

DISCUSSION

This work will be relevant to a broad range of RCTs addressing questions of effectiveness for strategies to improve practice and policy in the areas of social determinants of health, clinical care, health systems, public health, and international development, where health and/or access to health care is a primary outcome. The outcomes include a reporting guideline (CONSORT-equity extension) for equity-relevant RCTs and a knowledge translation strategy to broadly encourage its uptake and use by journal editors, authors, and funding agencies.

Managing the grazing dairy cow through the transition period: a review

The transition period of the dairy cow generally refers to the last three weeks of gestation and the first three weeks of lactation. During this period, the dairy cow faces numerous physiological challenges, requiring both homeostatic and homeorhetic changes to support the demands of lactation. Management strategies to achieve a successful transition have developed over many decades. Historically, these strategies focussed on achieving high energy intakes pre-calving in an attempt to improve post-calving metabolism; however, more recent research has indicated that this approach may not be appropriate. Physiological and molecular data have indicated that imposing a slight negative energy balance (EBAL) pre-calving can improve post-calving EBAL, metabolic health indices and milk production. It was hypothesised that the challenges of the transition period would be less in a grazing system than in an intensive confinement system, due to the lower milk production and the difference in population density and, therefore, pathogen exposure. However, the molecular and immunological responses to the change of state are similar in magnitude in a moderate-yielding pasture-fed cow and in a high-yielding cow fed a total mixed ration. The collective data point to a peripartum immunosuppression, which is affected by body condition score and feeding level. This review will outline the literature and provide an assessment of the most recent transition cow management for grazing dairy cows.

Whole-exome sequencing identifies rare and low-frequency coding variants associated with LDL cholesterol

Elevated low-density lipoprotein cholesterol (LDL-C) is a treatable, heritable risk factor for cardiovascular disease. Genome-wide association studies (GWASs) have identified 157 variants associated with lipid levels but are not well suited to assess the impact of rare and low-frequency variants. To determine whether rare or low-frequency coding variants are associated with LDL-C, we exome sequenced 2,005 individuals, including 554 individuals selected for extreme LDL-C (>98(th) or <2(nd) percentile). Follow-up analyses included sequencing of 1,302 additional individuals and genotype-based analysis of 52,221 individuals. We observed significant evidence of association between LDL-C and the burden of rare or low-frequency variants in PNPLA5, encoding a phospholipase-domain-containing protein, and both known and previously unidentified variants in PCSK9, LDLR and APOB, three known lipid-related genes. The effect sizes for the burden of rare variants for each associated gene were substantially higher than those observed for individual SNPs identified from GWASs. We replicated the PNPLA5 signal in an independent large-scale sequencing study of 2,084 individuals. In conclusion, this large whole-exome-sequencing study for LDL-C identified a gene not known to be implicated in LDL-C and provides unique insight into the design and analysis of similar experiments.

Neonatal respiratory failure due to a novel mutation in the surfactant protein C gene

A full-term infant developed respiratory distress immediately after birth, requiring a prolonged course of extra-corporeal membrane oxygenation, followed by high-frequency ventilation. She was unable to wean off mechanical ventilation, required tracheostomy, and ultimately lung transplantation. A novel mutation in the surfactant C protein gene was identified as the cause of her lung disease.

Age, gender, and race/ethnic differences in total body and subregional bone density

SUMMARY

Total body bone density of adults from National Health and Nutrition Examination Survey (NHANES) 1999-2004 differed as expected for some groups (men>women and blacks>whites) but not others (whites>Mexican Americans). Cross-sectional age patterns in bone mineral density (BMD) of older adults differed at skeletal sites that varied by degree of weight-bearing.

INTRODUCTION

Total body dual-energy X-ray absorptiometry (DXA) data offer the opportunity to compare bone density of demographic groups across the entire skeleton.

METHODS

The present study uses total body DXA data (Hologic QDR 4500A, Hologic, Bedford MA, USA) from the NHANES 1999-2004 to examine BMD of the total body and selected skeletal subregions in a wide age range of adult men and women from three race/ethnic groups. Total body, lumbar spine, pelvis, right leg, and left arm BMD and lean mass from 13,091 adults aged 20 years and older were used. The subregions were chosen to represent sites with different degrees of weight-bearing.

RESULTS

Mean BMD varied in expected ways for some demographic characteristics (men>women and non-Hispanic blacks>non-Hispanic whites) but not others (non-Hispanic whites>Mexican Americans). Differences in age patterns in BMD also emerged for some characteristics (sex) but not others (race/ethnicity). Differences in cross-sectional age patterns in BMD and lean mass by degree of weight-bearing in older adults were observed for the pelvis, leg, and arm.

CONCLUSION

This information may be useful for generating hypotheses about age, race, and sex differences in fracture risk in the population.

Risk factors for low BMD in healthy men age 50 years or older: a systematic review

SUMMARY

In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications.

INTRODUCTION

Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older.

MATERIALS AND METHODS

A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria.

RESULTS

Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss.

CONCLUSION

In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.

Risk factors for low bone mass in healthy 40-60 year old women: a systematic review of the literature

Based on a systematic review of the literature, only low body weight and menopausal status can be considered with confidence, as important risk factors for low BMD in healthy 40-60 year old women. The use of body weight to identify high risk women may reduce unnecessary BMD testing in this age group.

INTRODUCTION

BMD testing of perimenopausal women is increasing but may be unnecessary as fracture risk is low. Appropriate assessment among younger women requires identification of risk factors for low BMD specific to this population.

METHODS

We conducted a systematic literature review of risk factors for low BMD in healthy women aged 40-60 years. Articles were retrieved from six databases and reviewed for eligibility and methodological quality. A grade for overall strength of evidence for each risk factor was assigned.

RESULTS

There was good evidence that low body weight and post-menopausal status are risk factors for low BMD. There was good or fair evidence that alcohol and caffeine intake, and reproductive history are not risk factors. There was inconsistent or insufficient evidence for the effect of calcium intake, physical activity, smoking, age at menarche, history of amenorrhea, family history of OP, race and current age on BMD.

CONCLUSIONS

Based on current evidence in Caucasians, we suggest that, in healthy women aged 40-60 years, only those with a low body weight (< 70 kg) be selected for BMD testing. Further research is necessary to determine optimal race-specific discriminatory weight cut-offs and to evaluate the risk factors for which there was inconclusive evidence.

Nausea and vomiting in HIV: a symptom review

Nausea and vomiting are two of the most common symptoms experienced by those with HIV. While the causes are most commonly attributed to medication side effects, infectious causes, gastroparesis and psychosomatic, therapy aimed at controlling symptoms has not been well studied. Since nausea and vomiting have been identified as the most common cause of discontinuation of highly active antiretroviral therapy (HAART) therapy, and due to the extensive morbidity associated with these symptoms, we sought to review and discuss causes and management of these symptoms in HIV-infected patients and demonstrate the need for further research in this area. Such studies could include investigation into the prophylactic use of antiemetics with initiation or modification of HAART therapy to monitor patient compliance. In addition, anticipatory nausea and vomiting should be further studied, as it could prove to be quite prevalent, as in cancer patients.

Tetanus antibody protection among HIV-infected US-born patients and immigrants

INTRODUCTION

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients.

METHODS

A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml.

RESULTS

Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001).

CONCLUSION

The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.

Clinical trial: an efficacy evaluation of reduced bisacodyl given as part of a polyethylene glycol electrolyte solution preparation prior to colonoscopy

BACKGROUND

In an attempt to further improve patient preparation experience with reduced volume gut lavage solutions using 2-L sulphate-free electrolyte lavage solution plus 20-mg bisacodyl (HalfLytely with Bisacodyl Tablets Bowel Prep Kit, Braintree Laboratories, Inc., Braintree, MA, USA), a low bisacodyl dose preparation was developed using 10 mg bisacodyl.

AIM

To compare preparation methods using the 10- or 20-mg bisacodyl with 2-L sulphate-free electrolyte lavage method.

METHODS

At 10 US centres, 455 patients undergoing colonoscopy for routine clinical indications were equally randomized to receive 10- or 20-mg bisacodyl with 2-L sulphate-free electrolyte lavage method. Colonoscopists rated the efficacy of colon cleansing, blinded to the preparation assignment.

RESULTS

Physician assessment of colon cleansing showed no difference between those randomized to receive the 10- or 20-mg bisacodyl preparations (P = 0.52). The 10-mg preparation had lower symptom scores for cramping (P < 0.001) and overall discomfort (P = 0.001). Other reported adverse experiences were few, mild and not different between groups.

CONCLUSION

Two-litre sulphate-free electrolyte lavage method solution with 10-mg bisacodyl is as effective as the 20-mg bisacodyl preparation for cleansing the colon prior to colonoscopy. The 10-mg bisacodyl regimen has an improved safety profile, with significantly reduced cramping, nausea and overall discomfort.

Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research

ONJ has been increasingly suspected to be a potential complication of bisphosphonate therapy in recent years. Thus, the ASBMR leadership appointed a multidisciplinary task force to address key questions related to case definition, epidemiology, risk factors, diagnostic imaging, clinical management, and future areas for research related to the disorder. This report summarizes the findings and recommendations of the task force.

INTRODUCTION

The increasing recognition that use of bisphosphonates may be associated with osteonecrosis of the jaw (ONJ) led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address a number of key questions related to this disorder.

MATERIALS AND METHODS

A multidisciplinary expert group reviewed all pertinent published data on bisphosphonate-associated ONJ. Food and Drug Administration drug adverse event reports were also reviewed.

RESULTS AND CONCLUSIONS

A case definition was developed so that subsequent studies could report on the same condition. The task force defined ONJ as the presence of exposed bone in the maxillofacial region that did not heal within 8 wk after identification by a health care provider. Based on review of both published and unpublished data, the risk of ONJ associated with oral bisphosphonate therapy for osteoporosis seems to be low, estimated between 1 in 10,000 and <1 in 100,000 patient-treatment years. However, the task force recognized that information on incidence of ONJ is rapidly evolving and that the true incidence may be higher. The risk of ONJ in patients with cancer treated with high doses of intravenous bisphosphonates is clearly higher, in the range of 1-10 per 100 patients (depending on duration of therapy). In the future, improved diagnostic imaging modalities, such as optical coherence tomography or MRI combined with contrast agents and the manipulation of image planes, may identify patients at preclinical or early stages of the disease. Management is largely supportive. A research agenda aimed at filling the considerable gaps in knowledge regarding this disorder was also outlined.

Non-Fourier motion analysis

It has been realized for some time that the visual system performs at least two general sorts of motion processing. First-order motion processing applies some variant of standard motion analysis (i.e. spatiotemporal Fourier energy analysis) directly to stimulus luminance, whereas second-order motion processing applies standard motion analysis to one or another grossly non-linear transformation of stimulus luminance. We have developed a method for disentangling the different sorts of mechanisms that may operate in human vision to detect second-order motion. This method hinges on an empirical condition called transition invariance that may or may not be satisfied by a family psi of textures. Any failure of this condition indicates that more than one mechanism is involved in detecting the motion of stimuli composed of the textures in psi. We have shown that the family of sinusoidal gratings oriented orthogonally to the direction of motion and varying in contrast and spatial frequency is transition invariant. We modelled the results in terms of a single-channel motion computation. We have new results indicating that a specific class of textures differing in texture element density and texture element contrast decisively fails the test of transition invariance. These findings suggest that in addition to the single second-order motion channel required by our earlier results there exists at least one other second-order motion channel. We argue that the preprocessing transformation used by this channel is a pointwise non-linearity that maps stimulus contrasts of absolute value less than some relatively high threshold tau onto 0, but increases with magnitude of c-tau for contrasts. c of absolute value greater than tau.

Determining knowledge transfer gaps in the life cycle of evidence for chemotherapy in non-small cell lung cancer (NSCLC) through cumulative meta-analysis

6555

Background: The uptake of research findings into practice is often delayed (Antman et al. JAMA 1992). We investigated the relative role of evidence in determining clinical recommendations and practice for NSCLC. Novel chemotherapy agents (NCA) approved for use in Canada between 1992 and 2002 were eligible. Methods: We conducted a systematic review of evidence for vinorelbine (V), paclitaxel (P) and gemcitabine (G) in combination with a platinum agent for the treatment of advanced NSCLC. Primary endpoint of efficacy was median survival. For each included randomized controlled trial (RCT), the publications dates of abstracts and journal articles were considered. At each time point when new data was available, a new meta-analysis using the Follman methodology was performed. Bibliometric analyses were performed to identify key milestones for each drug (e.g. Health Canada Notice of Compliance, provincial drug funding, and clinical recommendations). Results: 3,399 references were obtained for NCA in advanced NSCLC. Eligibility review identified 20 references for V representing 6 RCTs (1994–2002), 16 for P representing 4 RCTs (1997–2000), and 10 for G representing 7 RCTs (1998–2003). All drugs trended towards median survival benefit throughout the time of analysis. However, over time the estimated effect for V became weaker, remained stable for P and became stronger for G. The 1997 ASCO guideline recommended V and P as standard therapy; G was only cited as a promising investigational agent. By 2003, the ASCO guideline recommended G as a standard. Only V received Ontario provincial funding in 1997, while G and P received funding in 2002 and 2003 respectively. Conclusions: This study demonstrates the relatively small pool of RCT evidence for NCAs. These three commonly used NCAs demonstrate different patterns of evolution of evidence. For advanced NSCLC, the time gap between evidence and clinical recommendations is short. Caution should be used for generating recommendations using early results, when the evidence base is not stable, which may either over or underestimate true effectiveness.

No significant financial relationships to disclose.

An open-label study of chronic polyethylene glycol laxative use in chronic constipation

BACKGROUND

Polyethylene glycol 3350 (MiraLAX, Braintree Laboratories Inc., Braintree, MA, USA) is approved for the short-term treatment of occasional constipation.

AIM

To extend the safety data of polyethylene glycol used for chronic treatment of chronic constipation.

METHODS

Study subjects who met defined criteria for chronic constipation were enrolled in this open-labelled, single-treatment multi-centre study to receive polyethylene glycol laxative as a single daily dose of 17 g for 12 months. Subjects returned to their study centres after 2, 4, 6, 9 and 12 months of treatment where blood and urine samples were collected and adverse events were reviewed. At each visit, subjects were queried for ROME constipation criteria and they rated their overall improvement using a global efficacy scale.

RESULTS

311 patients including 117, age 65 and older, were enrolled and received treatment at one of 50 centres. One hundred and eighty-four completed all 12 months of treatment. With respect to the 'Global Efficacy Assessment', depending on the month of observation, 80-88% of enrolled patients, and 84-94% of the elderly, were treated successfully. Similar results were obtained from secondary efficacy measures that assessed individual ROME constipation criteria at each visit. The response to treatment was durable over time. Over the 1-year course of study representing 218 patient-years at the labelled dose, medication-associated adverse effects were gastrointestinal complaints of diarrhoea, loose stool, flatulence and nausea. These effects were generally mild or moderate in severity. There were no clinically significant changes in haematology or blood chemistry, particularly electrolytes, for the study population as a whole or the elderly group.

CONCLUSIONS

Polyethylene glycol laxative is safe and effective for treating constipation in adult and elderly patients for periods up to 12 months, with no evidence of tachyphylaxis.

Calcium plus vitamin D supplementation and the risk of fractures

BACKGROUND

The efficacy of calcium with vitamin D supplementation for preventing hip and other fractures in healthy postmenopausal women remains equivocal.

METHODS

We recruited 36,282 postmenopausal women, 50 to 79 years of age, who were already enrolled in a Women's Health Initiative (WHI) clinical trial. We randomly assigned participants to receive 1000 mg of elemental [corrected] calcium as calcium carbonate with 400 IU of vitamin D3 daily or placebo. Fractures were ascertained for an average follow-up period of 7.0 years. Bone density was measured at three WHI centers.

RESULTS

Hip bone density was 1.06 percent higher in the calcium plus vitamin D group than in the placebo group (P<0.01). Intention-to-treat analysis indicated that participants receiving calcium plus vitamin D supplementation had a hazard ratio of 0.88 for hip fracture (95 percent confidence interval, 0.72 to 1.08), 0.90 for clinical spine fracture (0.74 to 1.10), and 0.96 for total fractures (0.91 to 1.02). The risk of renal calculi increased with calcium plus vitamin D (hazard ratio, 1.17; 95 percent confidence interval, 1.02 to 1.34). Censoring data from women when they ceased to adhere to the study medication reduced the hazard ratio for hip fracture to 0.71 (95 percent confidence interval, 0.52 to 0.97). Effects did not vary significantly according to prerandomization serum vitamin D levels.

CONCLUSIONS

Among healthy postmenopausal women, calcium with vitamin D supplementation resulted in a small but significant improvement in hip bone density, did not significantly reduce hip fracture, and increased the risk of kidney stones. (ClinicalTrials.gov number, NCT00000611.).

Design and baseline characteristics of the osteoporotic fractures in men (MrOS) study--a large observational study of the determinants of fracture in older men

Very little information is available to direct the prevention or management of osteoporosis in men. The Osteoporotic Fractures in Men (MrOS) Study is a prospective cohort study designed to examine the extent to which fracture risk is related to bone mass, bone geometry, lifestyle, anthropometric and neuromuscular measures, and fall propensity, as well as to determine how fractures affect quality of life in men. The study is also designed to understand how osteoporosis is related to prostate disease. At baseline, participants completed questionnaires regarding medical history, medications, physical activity, diet, alcohol intake, and cigarette smoking. Objective measures of anthropometric, neuromuscular, vision, strength, and cognitive variables were obtained. Skeletal assessments included DEXA, calcaneal ultrasound, and vertebral radiographs. Vertebral and proximal femoral QCT was performed on a subset (65%). Serum, urine, and DNA specimens were collected. After the baseline assessments, a questionnaire is mailed to participants every 4 months to ascertain incident falls, fractures, prostate cancer, and deaths. After an average of 4.5 years, participants are scheduled to return for a second comprehensive visit. Men were eligible if > or =65 years. 5995 men enrolled with a mean (+/-SD) age of 73.7 (+/-5.9) years, 11% of which were minorities. Most rated their health as good/excellent. Few were current smokers, although 59% had smoked previously, and 35% reported no alcohol intake, while 47% consumed at least 2 drinks per week. The mean (range) body mass index was 26.9 kg/m2 (17-56). A non-traumatic fracture after age 50 was reported by 17% of the cohort. The MrOS cohort should provide valuable information concerning the determinants of fracture in men and should help set the stage for the development of effective methods to identify those at risk.

Tobacco use prevention and cessation in dental and dental hygiene undergraduate education

Oral health care professionals are aware of their responsibility to advise patients to stop using tobacco. However, they do not feel sufficiently prepared to help their patients to quit, and consequently are not confident in providing these preventive measures. This fact reflects the lack of emphasis on tobacco cessation in both dental and dental hygiene undergraduate education. It may therefore be assumed that improvement of dental and dental hygiene education in tobacco use cessation counselling may result in increased self-confidence and frequency of its provision. The importance of making space in the curriculum for tobacco use prevention and cessation has to be emphasised. Dental schools and dental hygiene programmes have to be reminded of the key role the dental profession has in tobacco control. Next to the public health aspect of tobacco control, such involvement may be both an ethical and a legal responsibility. The implementation of effective tobacco use prevention and cessation in a dental educational setting requires a multidisciplinary approach involving the school's entire teaching personnel and external experts. In general, a knowledge base attained through lecture, Problem-Based Learning (PBL), or E-Learning, and clinical skills attained through clinical instructions and practices is required. It is suggested that curriculum content should include (1) the biological effects of tobacco use, (2) the history of tobacco culture and psychosocial aspects of tobacco use, (3) prevention and treatment of tobacco use and dependence, and (4) development of clinical skills for tobacco use prevention and cessation.

Impact of informed consent requirements on cardiac arrest research in the United States: exception from consent or from research?

INTRODUCTION

Research in patients with life-threatening illness such as cardiac arrest is challenging since they can not consent. The Food and Drug Administration addressed research under emergency conditions by publishing new criteria for exception from informed consent in 1996. We systematically reviewed randomized trials over a 10-year period to assess the impact of these regulations.

METHODS

Case-control study of published trials for cardiac arrest (cases) and atrial fibrillation (controls.) Studies were identified by using structured searches of MEDLINE and EMBASE from 1992 to 2002. Included were studies using random allocation in humans with cardiac arrest or atrial fibrillation prior to enrollment. Excluded were duplicate publications. Number of American trials, foreign trials and proportion of trials of American origin were compared by using regression analysis. Changes in cardiac arrest versus atrial fibrillation trials were calculated as risk differences.

RESULTS

Of 4982 identified cardiac arrest studies, 57 (1.1%) were randomized trials. The number of American cardiac arrest trials decreased by 15% (95% CI: 8, 22%) annually (P = 0.05). The proportion of cardiac arrest trials of American origin decreased by 16% (95% CI: 10, 22%) annually (P = 0.006). Of 5596 identified atrial fibrillation studies, 197 trials (3.5%) were randomized trials. The risk difference between cardiac arrest versus atrial fibrillation trials being of American origin decreased significantly (annual difference -5.8% (95% CI: -10, -0.1%), P = 0.03).

INTERPRETATION

Fewer American cardiac arrest trials were published during the last decade, when federal consent requirements changed. Regulatory requirements for clinical trials may inhibit improvements in care and threaten public health.

Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women's Health Initiative randomized trial

CONTEXT

In the Women's Health Initiative trial of estrogen-plus-progestin therapy, women assigned to active treatment had fewer fractures.

OBJECTIVE

To test the hypothesis that the relative risk reduction of estrogen plus progestin on fractures differs according to risk factors for fractures.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial (September 1993-July 2002) in which 16 608 postmenopausal women aged 50 to 79 years with an intact uterus at baseline were recruited at 40 US clinical centers and followed up for an average of 5.6 years.

INTERVENTION

Women were randomly assigned to receive conjugated equine estrogen, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102).

MAIN OUTCOME MEASURES

All confirmed osteoporotic fracture events that occurred from enrollment to discontinuation of the trial (July 7, 2002); bone mineral density (BMD), measured in a subset of women (n = 1024) at baseline and years 1 and 3; and a global index, developed to summarize the balance of risks and benefits to test whether the risk-benefit profile differed across tertiles of fracture risk.

RESULTS

Seven hundred thirty-three women (8.6%) in the estrogen-plus-progestin group and 896 women (11.1%) in the placebo group experienced a fracture (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.69-0.83). The effect did not differ in women stratified by age, body mass index, smoking status, history of falls, personal and family history of fracture, total calcium intake, past use of hormone therapy, BMD, or summary fracture risk score. Total hip BMD increased 3.7% after 3 years of treatment with estrogen plus progestin compared with 0.14% in the placebo group (P<.001). The HR for the global index was similar across tertiles of the fracture risk scale (lowest fracture risk tertile, HR, 1.20; 95% CI, 0.93-1.58; middle tertile, HR, 1.23; 95% CI, 1.04-1.46; highest tertile, HR, 1.03; 95% CI, 0.88-1.24) (P for interaction =.54).

CONCLUSIONS

This study demonstrates that estrogen plus progestin increases BMD and reduces the risk of fracture in healthy postmenopausal women. The decreased risk of fracture attributed to estrogen plus progestin appeared to be present in all subgroups of women examined. When considering the effects of hormone therapy on other important disease outcomes in a global model, there was no net benefit, even in women considered to be at high risk of fracture.

Statin use, clinical fracture, and bone density in postmenopausal women: results from the Women's Health Initiative Observational Study

BACKGROUND

3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been shown to stimulate bone formation in laboratory studies, both in vitro and in vivo. While early epidemiologic studies showed lower risk for hip fracture among statin users than nonusers, subsequent studies have produced mixed results.

OBJECTIVE

To examine the association of statin use with incidence of hip, lower arm or wrist, and other clinical fractures and with baseline levels of bone density.

DESIGN

Prospective study.

SETTING

Women's Health Initiative Observational Study conducted in 40 clinical centers in the United States.

PARTICIPANTS

93 716 postmenopausal women ages 50 to 79 years.

MEASUREMENTS

Rates of hip, lower arm or wrist, and other clinical fractures were compared among 7846 statin users and 85 870 nonusers over a median follow-up of 3.9 years. In 6442 women enrolled at three clinical centers, baseline levels of total hip, posterior-anterior spine, and total-body bone density measured by using dual-energy x-ray absorptiometry were compared according to statin use.

RESULTS

Age-adjusted rates of hip, lower arm or wrist, and other clinical fractures were similar between statin users and nonusers regardless of duration of statin use. The multivariate-adjusted hazard ratios for current statin use were 1.22 (95% CI, 0.83 to 1.81) for hip fracture, 1.04 (CI, 0.85 to 1.27) for lower arm or wrist fracture, and 1.11 (CI, 1.00 to 1.22) for other clinical fracture. Bone density levels did not statistically differ between statin users and nonusers at any skeletal site after adjustment for age, ethnicity, body mass index, and other factors.

CONCLUSION

Statin use did not improve fracture risk or bone density in the Women's Health Initiative Observational Study. The cumulative evidence does not warrant use of statins to prevent or treat osteoporosis.

Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed national science panel

OBJECTIVE

To assist in evaluating expert testimony and scientific evidence presented in law suits brought against silicone breast implant manufacturers, a US District Court Order established a National Science Panel to assess whether existing studies provide scientific evidence of an association between silicone breast implants and systemic classic/accepted connective disease, atypical connective disease, and certain signs and symptoms identified by plaintiffs in the law suits. Local disorders potentially associated with these implants were not addressed in this review. Therefore, we performed a systematic review of published studies on the association between silicone breast implants and systemic connective tissue disorders.

METHODS

Data from relevant studies (human cohort, case-control, or cross-sectional studies with > or = 10 participants and appropriate controls) were identified through literature searches of Medline, Current Contents, HealthStar, Biological Abstracts, EMBase, Toxline, and Dissertation Abstracts. Two independent reviewers, using standard collection forms, extracted data from the included studies. Adjusted relative risks (RRs) in cohort studies and odds ratios (ORs) in case-control and cross-sectional studies were reported if provided; otherwise, unadjusted RRs and ORs were calculated.

RESULTS

Twenty-four studies meeting inclusion criteria were identified. No association was evident between breast implants and any established or atypical connective tissue disorder. There was discordance among studies in reports of arthralgias, lymphadenopathy, myalgias, sicca symptoms, skin changes, and stiffness.

CONCLUSION

The panel found no evidence to support expert testimony suggesting an association between silicone breast implants and connective diseases. Discordance for symptoms may reflect differences in symptoms included in various categories, the small number of cases, and the effect of having single subjects with > 1 symptom represented in analyses of each symptom reported. The process presented here is an early example of the use of independent scientific panels to help courts clarify scientific evidence in legal proceedings.

The prevention of chronic NSAID induced upper gastrointestinal toxicity: a Cochrane collaboration metaanalysis of randomized controlled trials

OBJECTIVE

To review the effectiveness of common interventions for the prevention of nonsteroidal antiinflammatory drug (NSAID) induced upper gastrointestinal (GI) toxicity.

METHODS

Randomized controlled clinical trials (RCT) of prostaglandin analogs, H2-receptor antagonists (H2RA), or proton pump inhibitors (PPI) for the prevention of chronic NSAID induced upper GI toxicity were identified through electronic databases, the Cochrane control trials register, conference proceedings, and by contacting content experts and companies. Outcome measures investigated were endoscopic ulcers, ulcer complications, symptoms, overall dropouts, dropouts due to symptoms, and study quality.

RESULTS

Thirty-four RCT met the inclusion criteria. All doses of misoprostol significantly reduced the risk of endoscopic ulcers. Misoprostol 800 microg/day was superior to 400 microg/day for the prevention of endoscopic gastric ulcers (RR 0.18, RR 0.38, respectively; p = 0.0055). A dose-response relationship was not seen with duodenal ulcers. Misoprostol caused diarrhea at all doses, although significantly more at 800 than 400 microg/day (p = 0.0012). Misoprostol was the only prophylactic agent documented to reduce ulcer complications. Standard doses of H2RA were effective at reducing the risk of endoscopic duodenal (RR 0.24, 95% CI 0.10-0.57) but not gastric ulcers (RR 0.73, 95% CI 0.50-1.09). Both double dose H2RA and PPI were effective at reducing the risk of endoscopic duodenal and gastric ulcers (RR 0.44, 95% CI 0.26-0.74 and RR 0.37, 95% CI 0.27-0.51, respectively, for gastric ulcer) and were better tolerated than misoprostol.

CONCLUSION

Misoprostol, PPI, and double dose H2RA are effective in preventing chronic NSAID related endoscopic gastric and duodenal ulcers. Lower doses of misoprostol are less effective and are still associated with diarrhea. Only misoprostol 800 microg/day has been directly shown to reduce the risk of ulcer complications.

The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients

Clinical pathways have long been used to guide the delivery of patient care in varied practice settings. There is little information in the literature to document the effectiveness of pathway implementation in general surgical populations. This study reports the effect of clinical pathway implementation in two general surgical patient groups, thyroidectomy and parathyroidectomy. Clinical pathways were implemented to serve patients undergoing thyroidectomy and parathyroidectomy surgery. The effects of both clinical pathways on total hospital costs, length of hospitalization, variances, and outcomes were collected and evaluated from July 1998 through July 1999. These data were compared to data from the previous year. The average length of stay for parathyroidectomy patients decreased from 2.4 to 1.5 days (P = 0.26) for pathway patients as compared to prepathway patients. The average cost per case decreased from $5071 to $4291 (P = 0.50) for parathyroidectomy pathway versus prepathway patients. The average length of stay decrease for thyroidectomy patients was 1.4 to 1.2 (P = 0.16) for the pathway to prepathway comparison. The average cost per case decrease was minor at $4117 to $4111. Pharmacy costs and laboratory utilization were effectively reduced. Perioperative costs rose dramatically during this period, operating room/central sterile supply cost per case rose 12 per cent, anesthesia supply cost per case rose 15 per cent, and surgical pathology costs increased 110 per cent overall for both patient groups. Clinical pathway implementation has allowed us to reduce or maintain total hospital costs in the face of rising perioperative costs. We conclude that implementation of these clinical pathways has allowed us to improve consistency with which we deliver care while maintaining the quality of patient outcomes and reducing the costs of care and length of hospital stay.

Finger position for chest compressions in cardiac arrest in infants

OBJECTIVE

To determine whether the recommended method of locating finger position for chest compression in infant cardiac arrest can cause pressure on the abdomen or xiphisternum.

DESIGN

The length from the inter-nipple line to the xiphisternum was calculated in 30 infants. These lengths were compared with the finger position achieved by 30 adults, using the recommended method, on templates of infant chests.

RESULTS

The mean infant lower sternal length was 2.3 cm (95% CI 1.6). The mean distance covered by the adults fingers was 4.4 cm (95% CI 0.9).

CONCLUSION

If any infant in this study had chest compressions performed by any of the adults, using the recommended method, pressure would be exerted on the xiphisternum or abdomen. We suggest changing the method of locating finger position, to one using sternal anatomy.

Prevention of chronic NSAID induced upper gastrointestinal toxicity

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are important agents in the management of arthritic and inflammatory conditions, and are among the most frequently prescribed medications in North America and Europe. However, there is overwhelming evidence linking these agents to a variety of gastrointestinal (GI) toxicities.

OBJECTIVES

To review the effectiveness of common interventions for the prevention of NSAID induced upper GI toxicity.

SEARCH STRATEGY

A literature search was conducted, according to the Cochrane methodology for identification of randomized controlled trials in electronic databases, including MEDLINE from 1966 to January 2000, Current Contents for 6 months prior to January 2000, Embase to Febuary 1999, and a search of the Cochrane Controlled Trials Register from 1973 to 1999. Recent conference proceedings were reviewed and content experts and companies were contacted.

SELECTION CRITERIA

Randomized controlled clinical trials (RCTs) of prostaglandin analogues (PA), H2-receptor antagonists (H2RA) or proton pump inhibitors (PPI) for the prevention of chronic NSAID induced upper GI toxicity were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data regarding population characteristics, study design, methodological quality and number of patients with endoscopic ulcers, ulcer complications, symptoms, overall drop-outs, drop outs due to symptoms. Dichotomous data was pooled using Revman V3.1. Heterogeneity was evaluated using a chi square test.

MAIN RESULTS

Thirty-three RCTs met the inclusion criteria. All doses of misoprostol significantly reduced the risk of endoscopic ulcers. Misoprostol 800 ug/day was superior to 400 ug/day for the prevention of endoscopic gastric ulcers (RR=0.18, and RR=0. 38 respectively, p=0.0055). A dose response relationship was not seen with duodenal ulcers. Misoprostol caused diarrhea at all doses, although significantly more at 800ug/day than 400ug/day (p=0.0012). Misoprostol was the only prophylactic agent documented to reduce ulcer complications. Standard doses of H2RAs were effective at reducing the risk of endoscopic duodenal (RR=0.24; 95% CI: 0.10-0. 57) but not gastric ulcers(RR=0.73; 95% CI:0.50-1.09). Both double dose H2RAs and PPIs were effective at reducing the risk of endoscopic duodenal and gastric ulcers (RR=0.44; 95% CI:0.26-0.74 and RR=0.37;95% CI;0.27-0.51 respectively for gastric ulcer), and were better tolerated than misoprostol.

REVIEWER'S CONCLUSIONS

Misoprostol, PPIs, and double dose H2RAs are effective at preventing chronic NSAID related endoscopic gastric and duodenal ulcers. Lower doses of misoprostol are less effective and are still associated with diarrhea. Only Misoprostol 800ug/day has been directly shown to reduce the risk of ulcer complications.

Transcutaneous electrical nerve stimulation for knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a disease that affects synovial joints, which mainly causes degeneration and destruction of hyaline cartilage. To date, no curative treatment for OA exists. The primary goals for OA therapy are to relieve pain, maintain or improve functional status, and minimize deformity. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality in physiotherapy that is commonly used to control both acute and chronic pain arising from several conditions. A number of trials evaluating the efficacy of TENS in OA have been published.

OBJECTIVES

To assess the effectiveness of TENS in the treatment of knee OA. The primary outcomes of interest were those described by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) 3, which included pain relief, functional status, patient global assessment, and change in joint imaging for studies of one year or longer. The secondary objective was to determine the most effective mode of TENS application in pain control.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, HEALTHSTAR, PEDro, Current Contents and the Cochrane Controlled Trial Register using the Cochrane Musculoskeletal Group search strategy for trials up to and including December 1999. We also hand-searched reference lists and consulted content experts.

SELECTION CRITERIA

Two independent reviewers selected the trials that met predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted the data using standardized forms and assessed the quality of randomization, blinding and dropouts. A third reviewer was consulted to resolve any differences. For dichotomous outcomes, relative risks (RR) were calculated. For continuous data, weighted mean differences (WMD) or standardized mean difference (SMD) of the change from baseline were calculated. A fixed effects model was used unless heterogeneity of the populations existed. In this case, a random effects model was used.

MAIN RESULTS

Seven trials were eligible to be included in this review. Six used TENS as the active treatment while one study used acupuncture-like TENS (AL-TENS). A number of 148 and 146 patients were involved in the active TENS treatment and placebo, respectively. Three studies were cross-over studies and the others were parallel group, randomized controlled trials (RCTs). Median methodological quality of these studies was two. Pain relief from active TENS and AL-TENS treatment was significantly better than placebo treatment. Knee stiffness also improved significantly in active treatment group compared to placebo. Different modes of TENS setting (High Rate and Strong Burst Mode TENS) demonstrated a significant benefit in pain relief of the knee OA over placebo. Subgroup analyses showed a heterogeneity in the studies with methodological quality of three or more and those with repeated TENS applications.

REVIEWER'S CONCLUSIONS

TENS and AL-TENS are shown to be effective in pain control over placebo in this review. Heterogeneity of the included studies was observed, which might be due to the different study designs and outcomes used. More well designed studies with a standardized protocol and adequate number of participants are needed to conclude the effectiveness of TENS in the treatment of OA of the knee.

Thermotherapy for treating rheumatoid arthritis

BACKGROUND

Heat and cold therapy are often used as adjuncts in the treatment of rheumatoid arthritis by rehabilitation specialists.

OBJECTIVES

To evaluate the effects of heat and cold on objective and subjective measures of disease activity in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched Medline, Embase, PEDro, Current Contents, Sports Discus and CINAHL up to June 2000. The Cochrane Field of Rehabilitation and related therapies and the Cochrane Musculoskeletal Review Group were also contacted for a search of their specialized registers. Handsearching was conducted on all retrieved articles for additional articles.

SELECTION CRITERIA

Randomized or controlled clinical trials of ice or heat compared to placebo or active interventions in patients with rheumatoid arthritis and case-control and cohort studies were eligible. No language restrictions were applied. Abstracts were accepted.

DATA COLLECTION AND ANALYSIS

Two independent reviewers identified potential articles from the literature search. These reviewers extracted data using pre-defined extraction forms. Consensus was reached on all data extraction. Quality was assessed by two reviewers using a 5 point scale that measured the quality of randomization, double-blinding and description of withdrawals.

MAIN RESULTS

Three studies (79 subjects) met the inclusion criteria. There was no effect on objective measures of disease activity (including inflammation, pain and x-ray measured joint destruction) of either ice versus control or heat versus control. Patients reported that they preferred heat therapy to no therapy (94% like heat therapy better than no therapy). There was no difference in patient preference for heat or ice. No harmful effects of ice or heat were reported.

REVIEWER'S CONCLUSIONS

Since patients enjoy thermotherapy, and there are no harmful effects, thermotherapy should be recommended as a therapy which can be applied at home as needed to relieve pain. There is no need for further research on the effects of heat or cold for RA.

Appointment of a Resuscitation Training Officer is associated with improved survival from in-hospital ventricular fibrillation/ventricular tachycardia cardiac arrest

OBJECTIVE

To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospital ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.

DESIGN

A 22-month prospective study.

SETTING

A 1100-bed teaching hospital.

SUBJECTS

All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests.

INTERVENTIONS

Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitation training for all staff.

MAIN OUTCOME

Survival to discharge.

RESULT

Improvement in survival to discharge of 20-75% (P<0.03, Spearman Rank Correlation test).

CONCLUSION

Appointment of a Resuscitation Training Officer is associated with improved survival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest.

Heart failure due to ischaemic heart disease: epidemiology, pathophysiology and progression

Ischaemic heart disease is the most common underlying cause of heart failure in industrialised countries. Its manifestations are protean with myocardial infarction being only one important facet. The prognosis of patients with heart failure due to ischaemic heart disease also appears to be worse than that associated with many other aetiologies. The presence of ischaemic heart disease may influence both the efficacy and choice of treatment. Agents such as digoxin and amlodipine appear less effective in patients with ischaemic heart disease while ACE inhibitors and beta-blockers appear as or more effective in patients with ischaemic heart disease. Many have expressed an opinion about how coronary disease should be managed in the patient with heart failure supported by little or no evidence. There are major theoretical and practical concerns about the use of anti-coagulant, anti-platelet and statin therapy in patients with heart failure as well as major theoretical benefits. Only randomised controlled trials will resolve these issues. The same may be said of revascularisation. Fortunately trials addressing all these areas are under way. This should put the management of coronary disease in patients with heart failure on a firm evidence-based footing.

Management of hypothermias in adults

Hypothermia has a high mortality. Mortality will depend on duration and depth of cooling. Matching rewarming to these variables may improve survival.

Responsiveness of endpoints in osteoporosis clinical trials--an update

As an update of our earlier paper, published as part of the Outcome Measures in Rheumatology Clinical Trials (OMERACT 3) proceedings in 1996, we surveyed the types of outcomes incorporated in recent clinical trials. A literature search was conducted on MEDLINE and Current Contents, from January 1996 to March 1998, using the search strategy recommended by the Cochrane Collaboration for the identification of randomized controlled trials (RCT). Two independent reviewers selected trials according to inclusion criteria. The same reviewers extracted data on clinical and radiographic fractures, pain, quality of life, and bone mineral density (BMD). Seventy-four RCT conducted on bone loss in postmenopausal women were identified. Most trials incorporated biochemical markers and BMD as outcome measures. Fewer trials included vertebral fractures, pain, height, and quality of life. The responsiveness is presented in terms of the sample size needed per group to show a statistically significant difference. The most responsive outcomes were pain, BMD, and biochemical markers. The number needed to treat to prevent one vertebral fracture ranged from 13 to 54, depending on the intervention and population. Investigators should examine the characteristics of the patient population and the nature of the intervention in determining the sample size required to demonstrate a significant effect. The selection of endpoints should be based on their responsiveness, feasibility, and the importance of using standardized outcomes. Standardized outcomes greatly facilitate the synthesis of available information into systematic reviews by groups such as the Cochrane Collaboration.