A history of lameness and low body condition score is associated with reduced digital cushion volume, measured by magnetic resonance imaging, in dairy cattle

Claw horn lesions (CHL) are the result of a failing of the functional anatomy of the hoof in dairy cows. The digital cushion is understood to be a vital structure in the prevention of CHL. Claw horn lesions have previously been shown to lead to pathological change to the pedal bone; however, their effects on the digital cushion are unknown. The primary aim of this study was to examine associations between the history of CHL through an animal's life and the structure of the digital cushion at slaughter using magnetic resonance imaging. The retrospective cohort study resulted in the scanning of 102 pairs of hindfeet, collected from adult Holstein dairy cows culled from a research herd, using a 3-Tesla research-grade magnetic resonance imaging scanner. Volume and fat measurements were calculated for each digital cushion within each claw from a modified Dixon Quant sequence. Animal-level variables were constructed around the animals' lactating lifetime, with lameness scores and body condition score collected at least every 2 wk. The combined volume of digital cushion in the lateral claws was used as the outcome variable in multivariable linear models. The volume of the digital cushion was negatively associated with the number of lameness events or CHL recorded. Furthermore, animals with body condition score >3, culled later in lactation, or of a greater body weight were more likely to have a higher volume of digital cushion in the lateral claws. We propose that the observations made in the current study are the effects of a range of factors broadly associated with genetic, developmental, and disease-related inputs. Our understanding of how we can select for genetically more robust animals and how we can precondition the hoof before first calving needs to be improved to reduce the risk of future CHL in adult dairy cattle. Furthermore, understanding optimal treatment regimens and their effect on hoof anatomy may reduce the recurrence of CHL in the current lactation and future lactations.

Can a community empowerment intervention improve health and wellbeing in a post-industrial UK town?

Background

'Local People' programme operates in 29 UK communities experiencing disadvantage and economic stressors that impact on population wellbeing. The programme uses a community empowerment approach to increase social connections, and collective control, improve health, and reduce inequalities. This links to SDGs 3 and 11. Mechanisms include a decision-making group led by residents, a project lead, funding, and support from a national charity.

Methods

A mixed method evaluation was conducted (2017-19) to identify processes and assess outcomes and impacts. This presentation outlines the findings from five in-depth qualitative case studies (c140 interviews) with emphasis on one post-industrial UK town suffering from the effects of industrial decline. A within case and cross case qualitative analysis was undertaken using a thematic framework.

Results

Priorities set by local areas focused on increasing community involvement and connections between people. A wide range of activities took place including regular classes and community events. The five case studies found strong qualitative evidence of increased social connectedness, community spirit and a sense of purpose, along with the area becoming a better place to live. People involved in project delivery gained confidence and skills, improved their wellbeing and gained a sense of control. There is, as yet, limited evidence that increased involvement has influenced the wider determinants of health. In the post-industrial town, people's social networks expanded, enriching their lives and providing missed companionship. Participants in the programme reported improved mental and physical health, as well as increased confidence and skills. Involvement gave a voice to marginalised older people in the area.

Conclusions

Empowering communities and putting residents in control can lead to improvements in connectedness and some aspects of health and wellbeing, even in post-industrial towns facing considerable and complex challenges.

Key messages

The community empowerment programme increased social connectedness. The programme led to improved mental and physical health in participants.

An example of involving lay people to enhance complex public health intervention evaluations

Background

Despite growing interest in understanding complex systems and public health interventions, research methodologies that take account of system-wide action are relatively underdeveloped. Community-based participatory research (CBPR) is steered and conducted by people with lived experience of the issues being researched. This paper explores the value of CBPR in complex public health intervention evaluations. The 'Local People' and 'Local Conversations' programmes use a community empowerment approach in 50 communities across the UK experiencing social disadvantage to increase social connections and collective control, improve health and wellbeing, and reduce inequalities (linked to SDG 3 and 11).

Methods

Evaluation of the programmes followed a mixed-methods design, including qualitative case studies, longitudinal survey, process appraisal, and CBPR. Residents from 10 communities across the programmes each undertook 2 rounds of CBPR. These projects resulted in written reports, which were analysed thematically alongside other data sources.

Results

There was some variation in the scope and design of the 20 completed CBPR projects. Whilst projects did not generally extend beyond the scope of the overall evaluation, peer research provided information from residents that were inaccessible to other data collection streams. Gathering community (lay) knowledge improved understanding of local priorities and actions within the programmes. However, the utility of CBPR was less consistent for community-researchers and local communities, often failing to support project development. Some community-researchers felt unprepared for the activity despite support from the academic team.

Conclusions

Conducted appropriately, CBPR can elicit data that would be less accessible through externally led research. This study highlights the value of CBPR in complex programme evaluations, enabling a deeper understanding of social context in which interventions occur.

Key messages

CBPR complements more traditional research methodologies in complex public health evaluation designs. CBPR can enable a deeper understanding of social processes necessary for the success of complex public health interventions that might be beyond the scope of other methodologies.

Impact of a community empowerment programme in disadvantaged UK neighbourhoods: results of a survey

Background

A community empowerment programme in the UK aims to enable people to have greater collective control over area-based decision making, improved health and wellbeing and reduce health inequalities, by providing small grants to support residents of deprived neighbourhoods and communities of interest to come together to take action on issues of importance to them.

Methods

A survey was conducted at 4 6-month intervals as part of a mixed methods evaluation, to collect data about participant demographics, level of involvement, opinions of the project, and impacts. The survey was self-completed online or on paper, and distributed by local project leads. Outcome questions were adapted from the UK Government Community Life Survey to facilitate comparison with national statistics. Data were analysed using SPSS to produce descriptive statistics, supported by inferential statistical tests where appropriate. Regression analysis using multi-level modelling was used to estimate the conditional correlation between health outcome and Local People project participation.

Results

1053 people from 29 local areas responded to the survey over the 4 time points; only 93 responded more than once. 43% took part in project activities, 36% were local project committee members and 19% were volunteers. The analysis found positive impacts on confidence, control, friendships, skills, happiness, life satisfaction, feelings of worth (p < 0.05), and that greater length and degree of involvement in the projects were associated with greater positive impacts on all of these outcomes.

Conclusions

The survey provides tentative evidence that participation in a community empowerment initiative may result in improved wellbeing, feelings of power and control, sense of belonging and trust. People who are involved for longer or more deeply involved are more likely to see these impacts. More community-based survey research is needed to gather people's views on neighbourhood initiatives.

Key messages

An evaluation of a community empowerment programme found positive impacts on control, wellbeing, belonging and trust. Greater length or degree of involvement were associated with greater impact.

Community infrastructure to boost social relations: a systematic review

Background

‘Boosting social relations’ in communities has been identified as a priority UK policy-related topic. An earlier scoping review identified evidence gaps in social relations & community infrastructure. We undertook a mixed method systematic review on this topic, which has potential for immediate practical impact.

Methods

A comprehensive search included 11 databases (1997-2017), grey literature and citation checking. Studies of interventions to improve or make alternative use of community or neighbourhood places, reporting outcomes of social relations, community wellbeing & related concepts were included. Established validity checklists. Qualitative data was synthesised thematically and a narrative synthesis was produced. GRADE and CERQual approaches were used to rate the overall strength of evidence for each outcome.

Results

51 included studies, mostly of poor to moderate quality, and mostly qualitative, provided moderate evidence that: Community hubs may promote social cohesion, increase social capital and build trust, widen social networks, increase interaction, and increase knowledge or skills;Changes to neighbourhood design may positively affect sense of belonging and pride in a community;Green and blue space interventions that provide the opportunity to participate in activities or meetings may improve social interactions, increase social networks, bonding and bridging social capital, physical activity and healthy eating, and improve people’s skills and knowledge.

There were also common themes relating to facilitators and barriers to successful interventions.

Conclusions

There is moderate evidence that a range of intervention approaches to community infrastructure can boost social relations and community wellbeing. Future research should prioritise high quality evaluations using repeated measures and validated tools, and robust and credible qualitative evidence.

Key messages

There is moderate evidence that a range of intervention approaches to community infrastructure can boost social relations and community wellbeing. Community hubs may promote social cohesion, increase social capital and build trust, widen social networks, increase interaction, and increase knowledge or skills.

Whole systems approaches to obesity and other complex public health challenges: a systematic review

Background

Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs). We carried out a systematic review of WSAs targeting obesity and other complex public health and societal issues.

Methods

Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken.

Results

65 articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes.

Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance.

Conclusions

Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Key messages

Interventions working towards systems approaches are associated with a range of positive health outcomes. Evidence of systems science and systems thinking was less clear, even in the most “joined up” approaches.

P1732The additive value of pre- and post-reperfusion cardiac troponin T levels in risk stratification of patients with ST-segment elevation myocardial infarction

Background

Despite therapeutic advances, mortality rates following ST-segment elevation myocardial infarction (STEMI) are still alarmingly high. There is conflicting evidence regarding the prognostic role of high-sensitivity cardiac troponin T (hs-cTnT) measurements before and after primary percutaneous coronary intervention (PPCI) over traditional predictors of mortality in STEMI patients.

Purpose

To determine the additive prognostic value of pre- and 12h post-PPCI hs-cTnT levels in STEMI patients

Methods

Retrospective longitudinal study including 3,113 consecutive STEMI patients treated with PPCI at a university hospital covering a population of 1.6 million in the North East of England. Clinical, procedural, and laboratory data were prospectively collected during patient hospitalization while hs-cTnT measurements were performed at admission to the catheterization laboratory and at 12h post-PPCI. Median follow-up was 53 months. The study endpoints were in-hospital and overall mortality. Mortality data were obtained from the UK Office of National Statistics.

Results

Admission hs-cTnT >515ng/L (4th quartile) was independently associated with in-hospital mortality [HR=2.39 per highest to lower quartiles; 95% CI: 1.44 to 3.97; p=0.001] after multivariate adjustment for a core clinical model of in-hospital mortality prediction. Likewise, admission hs-cTnT >515ng/L independently predicted overall mortality (HR=1.25 per highest to lower quartiles; 95% CI: 1.00 to 1.57; p=0.044) after adjustment for covariates significantly associated with this endpoint. Admission hs-cTnT correctly reclassified risk for in-hospital death [net reclassification index (NRI)=44.1%, p<0.001) and overall mortality (NRI=60.4%, p<0.001). Conversely, 12h hs-cTnT was not independently associated with mortality.

Conclusion

Admission, but not 12h post-reperfusion, hs-cTnT predicts mortality and improves risk stratification in the PPCI era. These results support the role of hs-cTnT in risk stratification of post-STEMI patients and challenge the cost-effectiveness of routine 12h hs-cTnT measurements.

One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Impact of proctoring on success rates for percutaneous revascularisation of coronary chronic total occlusions

OBJECTIVE

To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres.

METHODS

We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case.

RESULTS

CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p<0.0001). In more complex cases where JCTO≥2, the difference in success was greater (70.7% vs 49.5%, p=0.0003). After proctoring, there was an increase in CTO PCI activity in centres from 2.5% to 3.5%, p<0.0001 (as a proportion of total PCI), and the proportion of very difficult cases with JCTO score ≥3 increased from 15.3% (35/229) to 29.7% (105/354), p<0.0001.

CONCLUSIONS

Proctoring resulted in an increase in procedural success for CTO PCI, an increase in complex CTO PCI and an increase in total CTO PCI activity. Proctoring may be a valuable way to improve access to CTO PCI and the likelihood of procedural success.

Nitrous oxide emissions from cattle excreta applied to a Scottish grassland: effects of soil and climatic conditions and a nitrification inhibitor

Dung and urine excreted onto grasslands are a major source of nitrous oxide (N2O). These N2O emissions stem from inefficient utilisation of nitrogen (N) ingested by ruminants, and the inability of pasture to utilise the deposited N. Predicted growth in dairy and meat consumption means that there is a requirement to quantify N2O emissions, and investigate emission reduction mechanisms. Three 12 month 'seasonal' experiments were undertaken at Crichton, SW Scotland, where N2O emissions were measured from applications of cattle urine, dung, artificial urine and urine+a nitrification inhibitor (NI), dicyandiamide (DCD). The three application timings were 'spring', 'summer' and 'autumn', representative of early-, mid- and late grazing seasons. N2O emissions were measured from static chambers for 12 months. The aim was to quantify emissions from cattle excreta, and determine their dependence on the season of application, and the respective contribution of dung and urine to total excreta emissions. Measurement from NI amended urine was made to assess DCD's potential as an emission mitigation tool. Emissions were compared to the IPCC's default emission factor (EF) of 2% for cattle excreted N. Mean annual cumulative emissions from urine were the highest when applied in summer (5034 g N2O-N ha(-1)), with lower emissions from spring (1903 g N2O-N ha(-1)) and autumn (2014 g N2O-N ha(-1)) application, most likely due to higher temperatures and soil moisture conducive to both nitrification and denitrification in the summer months. Calculated EFs were significantly greater from urine (1.1%) than dung (0.2%) when excreta was applied in summer, and EFs varied with season of application, but in all experiments were lower than the IPCC default of 2%. These results support both lowering and disaggregating this EF into individual EFs for dung and urine. Addition of DCD to urine caused no significant reduction in emissions, suggesting that more research is required into its use as a mitigation option.

Spinal fixation surgery for acute traumatic spinal cord injury

BACKGROUND

If the spine is unstable following traumatic spinal cord injury (SCI), surgical fusion and bracing may be necessary to obtain vertical stability and prevent re-injury of the spinal cord from repeated movement of the unstable bony elements. It has been suggested that this spinal fixation surgery may promote early rehabilitation and mobilisation.

OBJECTIVES

To answer the question: is there a difference in functional outcome and other commonly measured outcomes between people who have a spinal cord injury and have had spinal fixation surgery and those who have not?

SEARCH STRATEGY

The following databases were searched: AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED. Searches were updated in May 2003 and MEDLINE was searched again in May 2007. The reference lists of retrieved articles were checked.

SELECTION CRITERIA

Randomised controlled trials and controlled trials that compared surgical spinal fixation, with or without decompression, to any other treatment, in patients with a traumatic SCI.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies. One reviewer assessed the quality of the studies and extracted data.

MAIN RESULTS

No randomised controlled trials or controlled trials were identified that compared surgical spinal fixation surgery to other treatments in patients with a traumatic SCI. All of the studies identified were retrospective observational studies and of poor quality.

AUTHORS' CONCLUSIONS

The current evidence does not enable conclusions to be drawn about the benefits or harms of spinal fixation surgery in patients with traumatic SCI. Well-designed, prospective experimental studies with appropriately matched controls are needed.

Loxapine for schizophrenia

BACKGROUND

Some authors have suggested that loxapine is more effective than typical antipsychotics in reducing the negative symptoms of schizophrenia, that extrapyramidal adverse effects are not usually seen at clinically effective antipsychotic doses and that it should therefore be classed as atypical.

OBJECTIVES

To determine the effects of loxapine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

For this 2007 update, we searched the Cochrane Schizophrenia Group's Register (January 2007).

SELECTION CRITERIA

We included all randomised controlled clinical trials relevant to the care of schizophrenia that compared loxapine to other treatments.

DATA COLLECTION AND ANALYSIS

We independently inspected abstracts ordered papers, re-inspected and quality assessed these. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

MAIN RESULTS

We were able to include 41 studies in this review. Compared with placebo, loxapine has an antipsychotic effect (Global effect - not improved at six weeks: n=78, 2 RCTs, RR 0.30 CI 0.1 to 0.6 NNT 3 CI 3 to 5). It is as effective as typical drugs in the short term (4 -12 weeks) (Global effect: n=580, 13 RCTs, RR 0.86 CI 0.7 to 1.1; mental state: n=915, 6 RCTs, RR 0.89 CI 0.8 to 1.1). Very limited heterogeneous data suggest that, given intramuscularly (IM), loxapine may be at least as sedating as IM haloperidol and thiothixene. Loxapine is also as effective as atypicals (risperidone, quetiapine) (n=468, 6 RCTs, RR mental state not improved 1.07 CI 0.8 to 1.5). Adverse effect profile is similar to typicals but loxapine may cause more extrapyramidal adverse effects when compared with atypicals (n=340, 4 RCTs, RR 2.18 CI 1.6 to 3.1).

AUTHORS' CONCLUSIONS

Loxapine is an antipsychotic which is not clearly distinct from typical or atypical drugs in terms of its effects on global or mental state. Loxapines profile of adverse effects is similar to that of the older generation of antipsychotic drugs.

Molindone for schizophrenia and severe mental illness

BACKGROUND

Antipsychotic therapy is the mainstay of treatment for people with schizophrenia. In recent years new or atypical antipsychotics have been introduced. These are less likely to produce movement disorders and raise serum prolactin. Researchers have suggested that molindone should be classified as an atypical antipsychotic.

OBJECTIVES

To determine the effects of molindone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

For the original search we searched the following databases: Biological Abstracts (1980-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), CINAHL (1982-1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1999), PSYNDEX (1977-1999), and PsycLIT (1974-1999). We also searched pharmaceutical databases on the Dialog Corporation Datastar and Dialog and the references of all identified studies for further trials. Finally, we contacted the manufacturer of molindone and the authors of any relevant trials. For the update of this review, we searched The Cochrane Schizophrenia Group's Trials Register (August 2005).

SELECTION CRITERIA

We included all randomised controlled trials that compared molindone to other treatments for schizophrenia and schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently and analysed on an intention to treat basis calculating, for binary data, the fixed effect relative risk (RR), their 95% confidence intervals (CI), and the number needed to treat or harm (NNT or NNH). We excluded data if loss to follow up was greater than 50%.

MAIN RESULTS

We included fourteen studies. Duration ranged from very short (10 days) studies of the intramuscular preparation, to trials lasting over three months. For measures of global assessment, available data do not justify any conclusions on the comparative efficacy of molindone and placebo. When compared to other typical antipsychotics we found no evidence of a difference in effectiveness (doctors' 4 RCTs n=150, RR 1.13, CI 0.69 to 1.86; nurses 4RCTs n=146, RR 1.23, CI 0.82 to 1.86). Molindone is no more or less likely than typical drugs to cause movement disorders, but it does cause significantly more weight loss (2RCTs n=60 RR 2.78, CI 1.10 to 6.99, NNH 5 CI 2 to 77).

AUTHORS' CONCLUSIONS

The strength of the evidence relating to this compound is limited, owing to small sample size, poor study design, limited outcomes and incomplete reporting. Molindone may be an effective antipsychotic but its adverse effect profile does not differ significantly from that of typical antipsychotics (apart from the event of weight loss). Data from this review suggest, at present, there is no evidence to suggest that it may have an atypical profile.

Spinal injuries centres (SICs) for acute traumatic spinal cord injury

BACKGROUND

The majority of complications in traumatic spinal cord injury (SCI) can occur in the first 24 hours and it has been suggested that spinal injury centres (SICs) may influence the pre-transfer care of people with SCI. The specialist SIC concept has been adopted in a number of high-income countries. However, even in such countries, a potentially significant number of people with SCI do not have the opportunity to access this system and are managed in a non-specialist environment.

OBJECTIVES

To answer the question: does immediate referral to an SIC result in a better outcome than delayed referral?

SEARCH STRATEGY

The following databases were searched: AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED, and PsycLIT. Searches were updated in May 2003 and included the Cochrane Injuries Group Specialist Register. The reference lists of retrieved articles were checked.

SELECTION CRITERIA

Randomised controlled trials and controlled trials that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies. One reviewer was to have assessed the quality of the studies and extracted data.

MAIN RESULTS

No randomised controlled trials or controlled trials were identified that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI. All of the studies identified were retrospective observational studies and of poor quality.

REVIEWERS' CONCLUSIONS

The current evidence does not enable conclusions to be drawn about the benefits or disadvantages of immediate referral versus late referral to SICs. Well-designed, prospective experimental studies with appropriately matched controls are needed.

Interventions for the treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis



 The research evidence on the effectiveness of interventions for the treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) published in a recent issue of Effective Health Care is reviewed.

A rapid and systematic review of the clinical effectiveness and cost-effectiveness of topotecan for ovarian cancer

BACKGROUND

Ovarian cancer is the most common gynaecological cancer with an annual incidence of 21.6 per 100,000 in England and Wales. Due to the often asymptomatic nature of the early stages of the disease, most cases are not detected until the advanced stages. Consequently, the prognosis after diagnosis is poor and the 5-year survival rate in the UK is only about 30%. Current recommendations suggest that first-line chemotherapy for ovarian cancer should involve paclitaxel and platinum (Pt)-based therapy (cisplatin/ carboplatin), however, most patients develop resistant or refractory disease and require second-line therapy. Patients may respond to re-challenge with Pt-agents if the treatment-free interval is > 6 months, but an alternative is often required. Topotecan is one of six drugs currently licensed in the UK for second-line therapy, and recent reviews suggest that it has modest efficacy in the treatment of advanced disease and performs favourably against paclitaxel. However, these reviews are based on a limited number of reports mainly consisting of non-randomised Phase I and II studies.

OBJECTIVES OF THE REVIEW

To examine the clinical effectiveness and cost-effectiveness of oral and intravenous topotecan (Hycamtin, SmithKline Beecham, UK) for the treatment of all stages of ovarian cancer.

METHODS

SEARCH STRATEGY

Sixteen electronic databases from inception to September 2000 and Internet resources were searched, in addition to the bibliographies of retrieved articles and submissions from pharmaceutical companies.

METHODS

INCLUSION AND EXCLUSION CRITERIA

Two reviewers independently screened all titles/abstracts and included/excluded studies based on full copies of manuscripts. Any disagreements were resolved through discussion. Only randomised controlled trials (RCTs) and full economic evaluations comparing topotecan to non-topotecan regimens were included. All stages of therapy and disease were considered, and the outcomes included were survival, response, symptom relief, quality of life, adverse effects and costs.

METHODS

DATA EXTRACTION STRATEGY: Data were extracted into an Access database by one reviewer and checked by a second. Any disagreements were resolved through discussion.

METHODS

QUALITY ASSESSMENT STRATEGY: Two reviewers, using specified criteria, independently assessed the quality of the clinical effectiveness studies and the economic evaluations. Any disagreements were resolved through discussion.

METHODS

ANALYSIS STRATEGY: Due to the limited number of studies included in the review and the fact that they compared topotecan with different comparators, the out-come data could not be pooled statistically. Clinical effectiveness data are discussed separately under the different outcome subheadings. For time-to-event data, hazard ratios with 95% confidence intervals are presented where available, and for the remaining outcomes, relative risks are reported or calculated where sufficient data were available. Relative risk data are also presented in the form of Forest plots without pooled estimates. Economic data are presented in the form of a summary and critique of the evidence, and a grading (A-I) assigned to each study indicating the direction and magnitude of the cost-effectiveness data.

RESULTS

INCLUDED STUDIES

A total of 568 titles/abstracts were identified and screened for relevance. Full copies of 72 papers were assessed and seven published manuscripts reporting details of two studies of clinical effectiveness and one economic evaluation were included. Further details of the two clinical effectiveness studies and two new economic evaluations were identified from confidential company submissions. Overall, two international multicentre RCTs of effectiveness comparing topotecan with paclitaxel (trial 039) and topotecan with caelyx (trial 30-49) were included in the review. The three economic evaluations included in the review comprised one cost-minimisation analysis (CMA) comparing topotecan with caelyx, one cost-consequences analysis (CCA) comparing topotecan with paclitaxel, etoposide and altretamine and one cost-effectiveness analysis (CEA) comparing topotecan with paclitaxel.

RESULTS

QUALITY OF CLINICAL EFFECTIVENESS DATA: Both clinical effectiveness studies (trial 30-49 and 039) were of reasonable quality, although it was unclear whether either performed valid intention-to-treat analyses. In addition, trial 30-49 failed to state whether the outcome assessors were blinded to treatment allocation. RESULTS --QUALITY OF ECONOMIC EVALUATIONS: The CCA (comparing topotecan with three comparators) was of poor quality and of little relevance to the UK NHS. The CMA and CEA were of reasonable quality overall and relevant to the UK NHS. However, both, in particular the CEA, suffered from methodological problems, and thus their findings should be interpreted with caution.

RESULTS

ASSESSMENT OF CLINICAL EFFECTIVENESS: The assessment of clinical effectiveness was based on limited data. Only two trials with a total of 709 participants were identified. In general, with a few minor exceptions, there were no statistically significant differences between topotecan and paclitaxel, or topotecan and caelyx in survival, response rate, median time to response, median duration of response and quality of life. Significant differences that were reported were mainly identified in subgroup analyses (Pt-sensitive disease and disease without ascites) of questionable validity and their relevance to a general advanced ovarian cancer patient population undergoing second-line chemotherapy is unclear. However, statistically significant differences were observed in the incidence of adverse effects. Topotecan was associated with increased incidences of haematological toxicities (including neutropenia, leukopenia, anaemia and thrombocytopenia), alopecia, nausea and vomiting. Caelyx-treated patients suffered from significantly increased incidences of Palmar-Plantar erythrodysesthesia, stomatitis, mucous membrane disorders and skin rashes. Paclitaxel was associated with significant increases in alopecia, arthralgia, myalgia, neuropathy, paraesthesiae, skeletal pain and flushing.

RESULTS

ASSESSMENT OF COST-EFFECTIVENESS: The assessment of cost-effectiveness was also based on limited data, with three evaluations identified, one of which was not relevant. The two remaining studies, comparing topotecan with paclitaxel (CEA) and topotecan with caelyx (CMA), both used effectiveness data from multicentre RCTs and based their costs on 1999/2000 UK sources. The evaluations were conducted from a UK NHS perspective and findings presented in GB pounds/Euros. Topotecan for the second-line treatment of advanced ovarian cancer was shown to be more cost-effective than paclitaxel (32,513 GB pounds versus 46,186 GB pounds per person in terms of any response (complete or partial), incremental cost-effectiveness = 3065 GB pounds) in all respects except cost per time without toxicity or symptoms, but less cost-effective than caelyx (14,023 GB pounds versus 9979 GB pounds per person regardless of whether the patient responded). However, direct comparisons of the cost findings between the two studies is difficult because they used different designs, different time horizons for the cost analyses and the findings were presented as costs per person for only patients who responded in one study (topotecan versus paclitaxel) and costs per person regardless of whether they responded in the other study (topotecan versus caelyx).

CONCLUSIONS

This review indicates that there is little evidence in the form of RCTs on which to base an assessment of the effectiveness of topotecan as second-line therapy for advanced ovarian cancer. The evidence suggests there were no statistically significant differences overall between topotecan and paclitaxel, or topotecan and caelyx in clinical outcomes. However, statistically significant differences were observed in the incidence of adverse effects. The clinical significance of the findings is not discussed. Overall, the effects of topotecan could at best be described as modest, but the alternative agents offer no real advantages except fewer side-effects and possibly improved cost-effectiveness. Both of the clinical effectiveness studies on which this evidence is based had methodological flaws, the most serious being the lack of a blinded assessor in the topotecan versus caelyx trial, which is important for unbiased assessment of response outcomes. The economic evaluations also suffered from a number of potential problems.

CONCLUSIONS

RECOMMENDATIONS FOR RESEARCH: Further good quality RCTs and CEAs are required comparing topotecan with other licensed and potentially useful (soon to be licensed) second-line treatments for ovarian cancer. At present, it is difficult to make any decisions about topotecan and other drugs for second-line therapy without good quality direct comparisons. In view of the ongoing studies identified, an update of the current review should be considered in approximately 18 months (Summer 2002) or possibly sooner if the recently commissioned National Institute for Clinical Excellence review of caelyx for ovarian cancer identifies additional data relevant to topotecan.

Are selective endothelin A receptor antagonists better than mixed antagonists?

Pharmacological antagonism of the endothelin system presents a novel target for the treatment of a range of cardiovascular diseases. The antagonists developed so far differ in their endothelin receptor subtype specificity. Indeed, at present there is no consensus opinion as to what level of receptor selectivity defines a particular antagonist as 'selective' or 'mixed'. Antagonists that are highly selective for the endothelin A receptor (ETA) receptor subtype have a number of hypothetical advantages over non-selective antagonists. This theory is based on the analysis of the function of the endothelin B (ETB) receptor. Current evidence suggests that activation of the ETB receptor results in vasodilatation, diuresis and natriuresis, each of which are properties that might be advantageous to maintain in conditions such as cardiac failure and hypertension. However, definitive evidence to suggest a therapeutic advantage of selective ETA receptor antagonists requires long-term, head-to-head studies to be performed.

Interventions for the treatment and management of chronic fatigue syndrome: a systematic review

CONTEXT

A variety of interventions have been used in the treatment and management of chronic fatigue syndrome (CFS). Currently, debate exists among health care professionals and patients about appropriate strategies for management.

OBJECTIVE

To assess the effectiveness of all interventions that have been evaluated for use in the treatment or management of CFS in adults or children.

DATA SOURCES

Nineteen specialist databases were searched from inception to either January or July 2000 for published or unpublished studies in any language. The search was updated through October 2000 using PubMed. Other sources included scanning citations, Internet searching, contacting experts, and online requests for articles.

STUDY SELECTION

Controlled trials (randomized or nonrandomized) that evaluated interventions in patients diagnosed as having CFS according to any criteria were included. Study inclusion was assessed independently by 2 reviewers. Of 350 studies initially identified, 44 met inclusion criteria, including 36 randomized controlled trials and 8 controlled trials.

DATA EXTRACTION

Data extraction was conducted by 1 reviewer and checked by a second. Validity assessment was carried out by 2 reviewers with disagreements resolved by consensus. A qualitative synthesis was carried out and studies were grouped according to type of intervention and outcomes assessed.

DATA SYNTHESIS

The number of participants included in each trial ranged from 12 to 326, with a total of 2801 participants included in the 44 trials combined. Across the studies, 38 different outcomes were evaluated using about 130 different scales or types of measurement. Studies were grouped into 6 different categories. In the behavioral category, graded exercise therapy and cognitive behavioral therapy showed positive results and also scored highly on the validity assessment. In the immunological category, both immunoglobulin and hydrocortisone showed some limited effects but, overall, the evidence was inconclusive. There was insufficient evidence about effectiveness in the other 4 categories (pharmacological, supplements, complementary/alternative, and other interventions).

CONCLUSIONS

Overall, the interventions demonstrated mixed results in terms of effectiveness. All conclusions about effectiveness should be considered together with the methodological inadequacies of the studies. Interventions which have shown promising results include cognitive behavioral therapy and graded exercise therapy. Further research into these and other treatments is required using standardized outcome measures.

HIV risk behaviour among men who have sex with men in public sex environments: an ecological evaluation

Men who have sex with men (MSM) in public sex environments (PSE) may be at high risk for HIV/AIDS. The majority of research on HIV risk behaviour among MSM has been conducted in open access venues more likely to be linked to networks that openly endorse preventive messages and safer sex norms. This study investigated risk practices among MSM in a PSE in order to develop effective prevention intervention strategies. Three outreach workers with previous MSM prevention experience trained in ethnographic and fieldwork observation techniques provided direct observation data. Seventy-seven observations, each lasting a minimum of two hours, were conducted over a five-month period at three city public parks. Of 614 men observed, over 250 exhibited activities and behaviours related to, or potentially related, to HIV-risk relevant sexual behaviour. Direct sexual contact between two or more men was observed 19 times, while men entering or leaving a sex area of the park was observed 66 times. Outreach workers were able to interact directly with 72 MSM, primarily discussing safer sex strategies. Sexual encounters occurred in more open areas of the PSE with partners migrating to secluded areas for intense and sexual interactions. Future prevention interventions will need to be tailored, and targeted, to specific sexual exchange access points in PSE.

A transgenic strategy for analysis of the function of the endothelin-B-receptor

Knockout (KO) models have provided important insights into the function of many receptors and signalling molecules. However, analysis of endothelin (ET) receptor knockouts has been complicated by the development of lethal phenotypes. In this paper, we present our strategy for examining endothelin-B- (ET(B)) receptor function in the context of other strategies for rescuing the lethal phenotype of ET(B) knockout mice.

The Sixth International Conference on Endothelin. October 1999, Montreal, Canada

Since its discovery in 1988, there has been an enormous amount of interest in endothelin-1 (ET-1) and its regulatory and growth-promoting role in cardiovascular physiology. Evidence from the Sixth International Conference on Endothelin, held in Montreal in October 1999, continued to demonstrate that the endothelin system is an important therapeutic target in cardiovascular disease, with promising results in animal studies now being confirmed by clinical trials in humans. In addition, many new and exciting roles for ET-1 were presented, suggesting that ET-1 antagonism may have a broader therapeutic potential than previously imagined.

Loxapine for schizophrenia

BACKGROUND

Loxapine is a drug with D2/D3 receptor antagonist activity and a higher affinity for D3 than D2. Some authors have suggested that loxapine is more effective than typical antipsychotics in reducing the negative symptoms of schizophrenia, that extrapyramidal side-effects are not usually seen at clinically effective antipsychotic doses and that it should therefore be classed as atypical.

OBJECTIVES

To determine the effects of loxapine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1996), PSYNDEX (1977-1995) and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled clinical trials relevant to the care of schizophrenia that compared loxapine to other treatments.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted but excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Compared to placebo, loxapine is antipsychotic (Global effect - not improved at 6 weeks, n=66, RR 0.6 CI 0.4-0.9 NNT 4 CI 2-62) with similar adverse effect profile to typical drugs. Is as effective as typical drugs in the short term (4-12 weeks) (Global effect - not improved, n=411, RR 0.89 CI 0.7-1.2). Very limited heterogeneous data suggest that, given intramuscularly (IM), loxapine may be at least as sedating as IM haloperidol and thiothixene.

REVIEWER'S CONCLUSIONS

Loxapine is antipsychotic but its effects are under researched. It is not clearly different from typical drugs in either its positive or adverse effects.

Sertindole for schizophrenia

BACKGROUND

Sertindole is an atypical antipsychotic, which is thought to give a lower incidence of extrapyramidal side effects at clinically effective doses than typical antipsychotic drugs. In December 1998, Lundbeck Ltd., the manufacturers of sertindole, voluntarily suspended the availability of the drug due to concerns about cardiac arrhythmia and sudden cardiac death associated with its use. Sertindole has therefore been withdrawn from the market pending discussion with the European Regulatory Authority over cardiac safety.

OBJECTIVES

To determine the effects of sertindole compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), LILACS (1982-1996), MEDLINE (1966-1999), PSYNDEX (1977-1995) and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. The manufacturer of sertindole and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared sertindole to placebo or other antipsychotic drug treatments were included by independent assessment.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) or numbers needed to harm (NNH) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences (WMD) were calculated. All data were inspected for heterogeneity.

MAIN RESULTS

Two large important studies were excluded, because they did not report any usable data. The two that were included suggested that sertindole was more antipsychotic than placebo, as acceptable as placebo and better tolerated than haloperidol (NNT=9, RR 0.63 CI 0.41 to 0.96). Sertindole was associated with fewer movement disorders than haloperidol but was shown to cause more weight gain (NNH=9 RR 6.33, CI 1.92 to 20.92), rhinitis (NNH=8, RR 1.74, CI 1,28 to 2.36) and possibly male sexual dysfunction. Cardiac problems (QTc intervals of at least 500msec) were evident even in the randomised trials (NNH=13 RR 23, CI 1.37 to 386.60).

REVIEWER'S CONCLUSIONS

Because of the cardiac problems, even evident within poorly reported studies, at present sertindole should, if possible, be avoided. If sertindole is to be reintroduced, gold-standard evidence of its clinical benefits will need to far outweigh its real risks.

Zotepine for schizophrenia

BACKGROUND

Typical antipsychotic drugs are widely used as first line treatment for people with schizophrenia. The atypical class of antipsychotic drugs, however, is making important inroads into this approach and zotepine is one such compound. It is a dopamine antagonist and claimed to be to be particularly effective for negative symptoms

OBJECTIVES

To determine the effects of zotepine compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), CINAHL (1982-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), Dialog Corporation Datastar service (1999), MEDLINE (1966-1999), and PsycLIT (1974-1999) were undertaken. References of all identified studies were searched for further trials. Knoll Pharmaceuticals and authors of trials were contacted.

SELECTION CRITERIA

All randomised clinical trials that compared zotepine to other treatments for people with schizophrenia or other psychoses were included.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the relative risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) and numbers needed to harm (NNH), were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

All outcomes were short term (4-12 weeks). Limited data suggest that zotepine is an antipsychotic, at least as effective as typical drugs. Mental state measures of 'no clinically important improvement' favour zotepine when compared to other active drugs (n=356, RR 0.8 CI 0.7-0.9, NNT 7 CI 4-22). About one third of people in both zotepine and control groups left the studies before trial completion. Zotepine may result in less movement disorder adverse effects than typical antipsychotic drugs. Trials have not highlighted clear differences between zotepine and other atypical drugs.

REVIEWER'S CONCLUSIONS

Zotepine may be a valuable addition to the increasing ranks of atypical antipsychotic drugs. More data from already existing studies is urgently needed to increase the confidence in the findings of this review. New data from well planned, conducted and reported long term pragmatic randomised trials are necessary. Otherwise clinical use of zotepine will be based on speculation on the meaning of the findings of short explanatory trials for everyday practice.

Ziprasidone for schizophrenia and severe mental illness

BACKGROUND

Typical antipsychotic drugs are widely used as the first line treatment for people with schizophrenia. However, the atypical class of antipsychotic drugs are making important inroads into this approach. Atypical is a widely used term used to describe some antipsychotics which have a low propensity to produce movement disorders, sedation and raised serum prolactin. There is some suggestion that the different adverse effect profiles of the atypical antipsychotic group make them more acceptable to people with schizophrenia. Ziprasidone is one of the newer atypicals with a high serotonin/dopamine receptor affinity.

OBJECTIVES

To determine the effects of ziprasidone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1996), PSYNDEX (1977-1995) and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared ziprasidone to other treatments for schizophrenia and schizophrenia-like psychoses were included by independent assessment.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Data for this compound range from very short (1 week) studies of the intramuscular preparation, to trials lasting over six months. For measures of mental state ziprasidone seems more effective than placebo (RR 0.8 CI 0.7-0.9) and as effective as haloperidol (RR 0.8 CI 0.7-1). It is less likely than haloperidol to cause movement disorders (RR 0.4 CI 0.2-0.6), but may cause more nausea and vomiting (RR 2.1 CI 1.2-3.8). The injected form of the drug may cause more pain at the injection site than haloperidol (RR 5.3 CI 1.3-22).

REVIEWER'S CONCLUSIONS

Currently data are limited. Ziprasidone may be an effective antipsychotic with less extrapyramidal effects than haloperidol. It also may, however, cause more nausea and vomiting than the typical drugs, and, at present, there is no data suggesting that it is different to other atypical compounds. Well planned, conducted and reported long term randomised trials are needed if ziprasidone is to be accepted into everyday use.

Molindone for schizophrenia and severe mental illness

BACKGROUND

Typical antipsychotic drugs are widely used as the first line treatment for people with schizophrenia. However, the atypical class of antipsychotic drugs is making important inroads into this approach. 'Atypical' is a term widely used to describe some antipsychotics which have a low propensity to produce movement disorders, sedation and raised serum prolactin. There is some suggestion that the different adverse effect profiles of the atypical antipsychotic group make them more acceptable to people with schizophrenia. Molindone has a similar profile to quetiapine (a novel atypical antipsychotic), with very low binding to all receptors. Some authors have suggested that molindone is safer than other 'typical' antipsychotics in that extrapyramidal adverse effects are not usually seen at clinically effective antipsychotic doses and that it should therefore be classed as an atypical antipsychotic.

OBJECTIVES

To determine the effects of molindone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), CINAHL (1982-1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1999), PSYNDEX (1977-1999), and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. The manufacturer of molindone and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared molindone to other treatments for schizophrenia and schizophrenia-like psychoses were included by independent assessment.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences (WMD) were calculated. All data were inspected for heterogeneity.

MAIN RESULTS

Thirteen studies were included in the review. Data for this compound range from very short (10 day) studies of the intramuscular preparation to trials lasting over three months. For measures of global state available data do not justify any conclusions on the comparative efficacy of molindone and placebo. When compared to other typical antipsychotics no difference in effectiveness was evidenced (doctors' RR 1.13, CI 0.69 to 1.86; nurses' RR 1.23, CI 0.82 to 1.86). It is no more or less likely than typical drugs to cause movement disorders, but causes significantly more weight loss (RR 2.78, CI 1.10 to 6.99).

REVIEWER'S CONCLUSIONS

The strength of the evidence relating to this compound is limited, owing to small sample size, poor study design, limited outcomes and incomplete reporting. Molindone may be an effective antipsychotic; however, its adverse effect profile does not differ significantly from that of typical antipsychotics, apart from the event of weight loss. At present there is no evidence to suggest that it may have an atypical profile.

Risperidone versus other atypical antipsychotic medication for schizophrenia

BACKGROUND

Risperidone is one of a number of 'atypical antipsychotics' which are currently being marketed for the treatment of those with schizophrenia, largely on the basis of claims of improved tolerability and effectiveness compared to much cheaper conventional antipsychotics. The efficacy of risperidone has already been compared to conventional drugs, but it remains unclear how risperidone compares with other atypical antipsychotic drugs such as clozapine.

OBJECTIVES

To determine the effects of risperidone compared with other atypical antipsychotic drugs for schizophrenia.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library (Issue 1, 2000), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1999), PSYNDEX (1977-1999) and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled clinical trials that compared risperidone to other atypical antipsychotic treatments for schizophrenia and schizophrenia-like psychoses were included by independent assessment.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, standardised and weighted mean differences were calculated (SMD, WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Nine studies were obtained, comparing risperidone with clozapine (five studies - largely amongst treatment resistant patients); olanzapine (three studies); and amisulpiride (one study). The research was beset by problems of high attrition rates and short term follow up. Clozapine does seem equally acceptable to risperidone in the short term (leaving the study early, n=466, RR 1. 00 CI 0.73-1.37). For most other outcomes wide confidence intervals were obtained, which meant that it was impossible to judge whether the two compounds were equally effective, or whether one was in fact superior to the other. Olanzapine and risperidone seem broadly similar according to numbers of patients responding to treatment (40% reduction in PANSS scores: n=339, RR 1.14, CI 0.99-1.32). Olanzapine caused fewer people to leave the study early (n=404, RR 1. 31 CI 1.06-1.60; NNT 8 CI 4-32) and fewer extrapyramidal side effects (n=339, RR 1.67 CI 1.14-2.46; NNH 8 CI 5-33), although comparative doses of risperidone were higher than those recommended in practice. In one single study (n=228) amisulpiride seemed broadly similar to risperidone in most respects. There were no useful data presented relating to service use and costs. Very few data relating to quality of life were presented.

REVIEWER'S CONCLUSIONS

The equivalence of clozapine and risperidone for treatment resistant schizophrenia cannot yet be assumed and there seems to be little to chose between risperidone and both olanzapine and amisulpiride. The research is limited in many respects, and longer term studies measuring clinically important outcomes, including service use and quality of life are needed to judge the comparative value of the various atypical drugs.

Videofluoroscopic evaluation in the assessment of swallowing disorders in paediatric and adult populations

Videofluoroscopic swallow studies (VFSS) are often considered the 'gold standard' technique to assess dysphagia. Despite this status, unanimous agreement has not been reached regarding the protocol for this procedure. Review of the literature reveals two main schools of thought. The first advocates a uniform, standardised protocol used with all patients. The second argues for functional, tailor-made studies, which aim to elicit a sample of swallowing representative of typical feeding patterns. This paper reviews the literature on VFSS methodology and evaluates the applicability of protocols to the paediatric population. Broadly speaking, adult protocols tend towards uniform procedures, whereas paediatric studies aim to be more individualised and tailor-made. Clinical recommendations based upon VFSS are examined in the light of validity and reliability issues. The need for standardisation of the VFSS procedure is highlighted. The question is raised whether it is possible to achieve uniformity and consistency between clinicians and still perform patient-centered, tailor-made VFSSs, which are truly representative of a patient's swallow function. It is revealed that dysphagia specialists should achieve greater consistency in the VFSS procedure before claiming to be implementing a 'gold standard' technique.

Feeding problems in merosin deficient congenital muscular dystrophy

Feeding difficulties were assessed in 14 children (age range 2-14 years) with merosin deficient congenital muscular dystrophy, a disease characterised by severe muscle weakness and inability to achieve independent ambulation. Twelve of the 14 children were below the 3rd centile for weight. On questioning, all parents thought their child had difficulty chewing, 12 families modified the diet, and 13 children took at least 30 minutes to complete a meal. On examination the mouth architecture was abnormal in 13 children. On videofluoroscopy only the youngest child (2 years old), had a normal study. The others all had an abnormal oral phase (breakdown and manipulation of food and transfer to oropharynx). Nine had an abnormal pharyngeal phase, with a delayed swallow reflex. Three of these also showed pooling of food in the larynx and three showed frank aspiration. These six cases all had a history of recurrent chest infections. Six of eight children who had pH monitoring also had gastro-oesophageal reflux. As a result of the study five children had a gastrostomy, which stopped the chest infections and improved weight gain. This study shows that children with merosin deficient congenital muscular dystrophy have difficulties at all stages of feeding that progress with age. Appropriate intervention can improve weight gain and reduce chest infections. The severity of the problem has not been previously appreciated in this disease, and the study shows the importance of considering the nutritional status in any child with a primary muscle disorder.

Effect of fluticasone propionate aqueous nasal spray on allergen-induced inflammatory changes in the nasal airways of allergic rhinitics following exposure to nitrogen dioxide

BACKGROUND

The authors have recently demonstrated that prior exposure for 6 h to 400 p.p.b. nitrogen dioxide significantly enhances the early phase response of eosinophils in the nasal airways of allergic rhinitics to subsequent allergen provocation.

OBJECTIVE

To investigate whether treatment with fluticasone propionate aqueous nasal spray (FP) can alter the inflammatory response in the nasal airways under these conditions.

METHODS

Sixteen allergic, rhinitic patients were recruited for this double-blind, randomized, cross-over study and received either topical FP 200 microg once daily or matched placebo for 4 weeks. At the end of treatment, all underwent nasal lavage followed by a 6 h exposure to 400 p.p.b. NO2. Following exposure to NO2, nasal allergen challenge was performed and nasal lavage repeated. After a 4 week washout period, patients were given alternate treatment and tested as above.

RESULTS

Analysis of eosinophil cationic protein (ECP) in lavage samples from patients treated with placebo, demonstrated that this was significantly increased from a median value of 2.3 ng/mL (range: 1.0-7.1) to 15.1 ng/mL (range: 1.5-40.0; P = 0.001) following exposure to NO2 and allergen challenge. However, in patients treated with FP, ECP concentrations only increased from 3.3 ng/mL (range: 0.2-9.2) to 5.1 ng/mL (range: 0.3-20.0; P = 0.034) following exposure to NO2 and allergen challenge. The difference of the changes in ECP concentration between the placebo and the FP-treated group was significant (P = 0.003). Similarly, there was a significant increase in the number of eosinophils in nasal lavage after exposure to NO2 and allergen challenge in the placebo group, and this increase was inhibited in FP group (P = 0.002).

CONCLUSION

These results suggest that FP influences NO2- and allergen-induced changes in eosinophil function, as well as eosinophil number in the nasal airway of allergic rhinitics.