Post 12: December 23rd 2005
Links are given to online full text resources, all other materials can be obtained via the Fade Library, just mail your request to library.services@fade.nhs.uk
Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis (Roderick) 94 pages, Volume 9, number 49
This study showed that graduated compression stockings (and other mechanical compression methods) reduced the risk of deep venous thrombosis and pulmonary embolism in a wide range of surgical patients. Oral anticoagulants (such as warfarin) and infusions of dextran were also effective, although they appeared less protective than heparin-based regimens. In operations where regional anaesthesia is feasible, it resulted in a lower risk of venous thromboembolism than general anaesthesia, thus adding to any benefits from mechanical and pharmacologic methods.
Cardiovascular Diseases and Disorders; Treatment; Health Technology Assessment
The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children (Dretzke) 250 pages, Volume 9, number 50
For the effectiveness review, relevant studies were identified and evaluated. A quantitative synthesis of behavioural outcomes across trials was also undertaken using two approaches: vote counting and meta-analysis. The economic analysis consisted of reviewing previous economic/cost evaluations of parent training/education programmes and the economic information within sponsor’s submissions; carrying out a detailed exploration of costs of parent training/education programmes; and a de novo modelling assessment of the cost-effectiveness of parent training/education programmes. The potential budget impact to the health service of implementing such programmes was also considered.
Behaviour Disorders; Education; Health Technology Assessment; Cost Effectiveness
How to put NICE guidance into practice: A guide to implementation for organisations
The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. NICE guidance aims to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness.
Clinical Guidelines
Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints: systematic review and economic evaluation (Clar) 98 pages, Volume 9, number 47
Evidence on clinical effectiveness was obtained from randomised trials, supplemented by data from selected observational studies for longer term results, and for the natural history of chondral lesions. Because of a lack of long-term results on outcomes such as later osteoarthritis and knee replacement, only illustrative modelling was done, using a range of assumptions that seemed reasonable, but were not evidence based.
Joint Diseases; Prosthesis; Health Technology Assessment; Cost Effectiveness
Systematic review of effectiveness of different treatments for childhood retinoblastoma (McDaid) 162 pages, Volume 9, number 48
Study suggested that the evidence base for the relative effectiveness of treatments for childhood retinoblastoma is not sufficiently robust to provide clear guidance for clinical practice.
Eye Health; Treatment; Health Technology Assessment
Latest Guidelines
Health Protection Agency (2004) Interim UK guidelines for management of close community contacts of invasive group A streptococcal disease. Communicable Disease and Public Health 7(4) 354 - 361.
Summary: Group A streptococci cause a wide range of illnesses from non-invasive disease such as pharyngitis to more severe invasive infections such as necrotising fasciitis.
There remains uncertainty about the risk of invasive disease among close contacts of an index case of invasive disease and whether this risk warrants antibiotic prophylaxis. A 19-200 fold increased risk among household contacts has been reported in the literature. Recommendations for antibiotic prophylaxis regimens vary by country. A comprehensive literature review together with preliminary analysis of 2003
United Kingdom data from the strep-EURO programme informed the interim
recommendations of an expert working group. The evidence base to formulate
definitive guidance is weak. Risk calculations based on provisional UK data estimated
that over 2,000 contacts would need to receive antibiotic prophylaxis to prevent a
subsequent case of invasive group A streptococcal disease. The Working Group
considered that currently available evidence did not warrant the routine
administration of chemoprophylaxis to all close community contacts. More robust
risk estimates will be derived from ongoing UK surveillance data to inform a review
of this guidance in 2005.
Communicable Diseases
SIGN(2005) Management of breast cancer in women. Edinburgh: Sign.
SIGN has issued a new guideline on breast cancer, to replace the one published in 1998. It includes updated recommendations in several areas such as psychological issues, surgery, radiotherapy techniques and systemic treatments. It also focuses attention on the evidence to support practices in the more controversial areas.
Technorati Tags: Fade Breast Cancer; Fade Cancer
Improving Outcomes in Brain and Other CNS tumours, second consultation
This is the latest guidance document in the Improving Outcomes in Cancer series and gives advice on the service arrangements for patients with brain and other central nervous system (CNS) tumours.
Technorati Tags: Fade Neurological Diseases and Disorders; Fade Cancer
New Essence of Care Eureka: Protecting Patients Meal Times at St Michaels Community Hospital
Meal times weren’t a social occasion, but a time often disrupted by visitors, GPs and other health professionals visiting patients.
Technorati Tags: Fade Clinical Governance
Joseph Rowntree Foundation (2005) User perceptions of occasional and controlled heroin use. York: Joseph Rowntree Foundation.
A study, by the Institute for Criminal Policy Research, King’s College London, focused on a population of non-dependent and controlled dependent heroin users who saw their use as relatively problem-free. Using in-depth interviews with 51 people and an internet survey of 123 people, this study explored their experiences of heroin use.
Technorati Tags: Fade Drug Use
Latest Reports
Royal College of Physicians (2005) Doctors in society Medical professionalism in a changing world. London: RCP
This report sees the values of medical professionalism as fundamental not only to the integrity of the doctor-patient partnership but also to the roles of doctors in the life of our society. Under six main themes - leadership, teams, education, appraisal, careers and research - the report makes clear, practical recommendations that will lead not only to further improvements in patient care, but also offer more challenging and fulfilling lives for doctors.
Technorati Tags: Fade Medical Staff
Management, prevention and surveillance of Clostridium difficile Interim findings from a national survey of NHS acute trusts in England
The Health Protection Agency and the Healthcare Commission have published interim findings from a national survey of NHS acute trusts in England
The survey looked at:
The findings revealed that over a third of trusts surveyed did not routinely follow government guidelines on the management of Clostridium difficile infection in their hospitals.
Health Select Committee (2005) Health - First Report: Smoking in Public Places. London: Health Select Committee
Recommend that the Government introduce a comprehensive ban on smoking in all public places and workplaces, which includes Crown property and which has very limited exemptions. This is primarily an issue of protecting workers in the workplace, and all employers have a duty of care in this regard. It is unacceptable for the Government to allow any worker to be excluded from protection from SHS on the grounds of public opinion, especially when these grounds are specious. Moreover, a comprehensive ban would be easier and more cost-effective to implement and enforce, and would be more intelligible to the public. The ban introduced in Ireland has been a popular model which the UK Government would do well to follow.
Technorati Tags: Fade Smoking; Fade Public Health
HPA National Influenza Report 2005/2006
Influenza reports are produced fortnightly but will be published on a weekly basis when influenza activity begins to increase. Between reports, a short summary of the week's activity will be made available. The next complete influenza report will be published on Wednesday 04 January 2005.
Technorati Tags: Fade Influenza; Fade Statistical Data
Evidence from Journals
Rachel Huxley, Federica Barzi, Mark Woodward. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ.
Objective: To estimate the relative risk for fatal coronary heart disease associated with diabetes in men and women.
Design: Meta-analysis of prospective cohort studies.
Data sources: Studies published between 1966 and March 2005, identified through Embase and Medline, using a combined text word and MESH heading search strategy, in addition to studies from the Asia Pacific Cohort Studies Collaboration.
Review methods: Studies were eligible if they had reported estimates of the relative risk for fatal coronary heart disease comparing men and women with and without diabetes. Studies were excluded if the estimates were not adjusted at least for age.
Results: 37 studies of type 2 diabetes and fatal coronary heart disease among a total of 447 064 patients were identified. The rate of fatal coronary heart disease was higher in patients with diabetes than in those without (5.4 v 1.6%). The overall summary relative risk for fatal coronary heart disease in patients with diabetes compared with no diabetes was significantly greater among women than it was among men: 3.50, 95% confidence interval 2.70 to 4.53 v 2.06, 1.81 to 2.34. After exclusion of the eight studies that had adjusted only for age, the difference in risk between the sexes was substantially reduced but still highly significant. The pooled ratio of the relative risks (women: men) from the 29 studies with multiple adjusted estimates was 1.46 (1.14 to 1.88).
Conclusions: The relative risk for fatal coronary heart disease associated with diabetes is 50% higher in women than it is in men. This greater excess coronary risk may be explained by more adverse cardiovascular risk profiles among women with diabetes, combined with possible disparities in treatment that favour men.
Technorati Tags: Fade Diabetes; Fade Coronary Diseases and Disorders; Fade Diabetes
Low N, McCarthy A, Roberts TE, Huengsberg M, Sanford E, Sterne JA, Macleod J, Salisbury C, Pye K, Holloway A, Morcom A, Patel R, Robinson SM, Horner P, Barton PM, Egger M. Partner notification of chlamydia infection in primary care: randomised controlled trial and analysis of resource use. BMJ. 2005 Dec 15.
OBJECTIVE: To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection.
DESIGN: Randomised controlled trial.
SETTING: 27 general practices in the Bristol and Birmingham areas.
PARTICIPANTS: 140 men and women with chlamydia (index cases) diagnosed by screening of a home collected urine sample or vulval swab specimen.
INTERVENTIONS: Partner notification at the general practice immediately after diagnosis by trained practice nurses, with telephone follow up by a health adviser; or referral to a specialist health adviser at a genitourinary medicine clinic.
MAIN OUTCOME MEASURES: Primary outcome was the proportion of index cases with at least one treated sexual partner. Specified secondary outcomes included the number of sexual contacts elicited during a sexual history, positive test result for chlamydia six weeks after treatment, and the cost of each strategy in 2003 sterling prices.
RESULTS: 65.3% (47/72) of participants receiving practice nurse led partner notification had at least one partner treated compared with 52.9% (39/68) of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% confidence interval -1.8% to 26.5%). Of 68 participants referred to the clinic, 21 (31%) did not attend. The costs per index case were pound32.55 for the practice nurse led strategy and pound32.62 for the specialist referral strategy.
CONCLUSION: Practice based partner notification by trained nurses with telephone follow up by health advisers is at least as effective as referral to a specialist health adviser at a genitourinary medicine clinic, and costs the same.
Technorati Tags: Fade STDs; Fade Primary Care; Fade Cost Effectiveness
Liker H, Hungin P, Wiklund I. Managing gastroesophageal reflux disease in primary care: the patient perspective. J Am Board Fam Pract. 2005 Sep-Oct;18(5):393-400
Gastroesophageal reflux disease (GERD) is a chronic disease that affects up to 20% of the population of Western countries and accounts for around 5% of a primary-care physician's workload. A better understanding of how GERD affects many aspects of patients' lives may aid the management of patients in primary care. We conducted a systematic review of the effect of GERD on health-related quality of life (HRQL) in the primary-care setting and in the community. Validated questionnaires have shown that GERD patients consulting in primary care experience substantial reductions in both physical and psychosocial aspects of HRQL, as well as work productivity. Impairments in HRQL are seen whether or not reflux esophagitis or Barrett's esophagus is present on endoscopy, and are comparable with or worse than those seen in patients with other chronic diseases such as heart disease, diabetes, and cancer. Surveys in primary care and in the community highlight disrupted sleep, reduced concentration at work, and interference with physical activities such as exercise, housework, and gardening. Psychosocial aspects of patient well-being are also impaired, including enjoyment of social gatherings, intimacy, sex, and many individuals with GERD remain worried about the underlying cause of their symptoms. In conclusion, many aspects of HRQL are impaired in GERD patients. The primary-care physician is uniquely placed to assess and address the impact of GERD on patients' lives.
Technorati Tags: Fade Gastroesophageal Reflux Disease
David J Muscatello , Tim Churches , Jill Kaldor , Wei Zheng , Clayton Chiu , Patricia Correll and Louisa Jorm. An automated, broad-based, near real-time public health surveillance system using presentations to hospital Emergency Departments in New South Wales, Australia. BMC Public Health 2005, 5:141
Background: In a climate of concern over bioterrorism threats and emergent diseases, public health authorities are trialling more timely surveillance systems. The 2003 Rugby World Cup (RWC) provided an opportunity to test the viability of a near real-time syndromic surveillance system in metropolitan Sydney, Australia. We describe the development and early results of this largely automated system that used data routinely collected in Emergency Departments (EDs).
Methods: Twelve of 49 EDs in the Sydney metropolitan area automatically transmitted surveillance data from their existing information systems to a central database in near real-time. Information captured for each ED visit included patient demographic details, presenting problem and nursing assessment entered as free-text at triage time, physician-assigned provisional diagnosis codes, and status at departure from the ED. Both diagnoses from the EDs and triage text were used to assign syndrome categories. The text information was automatically classified into one or more of 26 syndrome categories using automated 'naive Bayes' text categorisation techniques. Automated processes were used to analyse both diagnosis and free text-based syndrome data and to produce web-based statistical summaries for daily review. An adjusted cumulative sum (cusum) was used to assess the statistical significance of trends.
Results: During the RWC the system did not identify any major public health threats associated with the tournament, mass gatherings or the influx of visitors. This was consistent with evidence from other sources, although two known outbreaks were already in progress before the tournament. Limited baseline in early monitoring prevented the system from automatically identifying these ongoing outbreaks. Data capture was invisible to clinical staff in EDs and did not add to their workload.
Conclusions: We have demonstrated the feasibility and potential utility of syndromic surveillance using routinely collected data from ED information systems. Key features of our system are its nil impact on clinical staff, and its use of statistical methods to assign syndrome categories based on clinical free text information. The system is ongoing, and has expanded to cover 30 EDs. Results of formal evaluations of both the technical efficiency and the public health impacts of the system will be described subsequently.
Technorati Tags: Fade Public Health; Fade Informatics
Small CB, et al. Efficacy and safety of mometasone furoate nasal spray in nasal polyposis. J Allergy Clin Immunol 2005 Dec;116(6):1275-1281.
BACKGROUND: Studies have suggested that topical corticosteroids are effective in the treatment of nasal polyps; however, this has yet to be confirmed in a large, robust clinical trial.
OBJECTIVE: To evaluate the efficacy and safety of mometasone furoate nasal spray (MFNS) for nasal polyposis.
METHODS: A total of 354 subjects with bilateral nasal polyps and clinically significant congestion/obstruction participated in this multinational, randomized, double-blind, placebo-controlled study. Subjects received MFNS 200 mug once or twice daily or placebo for 4 months. Coprimary endpoints were (1) change from baseline to last assessment in physician-evaluated bilateral polyp grade score and (2) change from baseline averaged over month 1 in subject-assessed nasal congestion/obstruction. ANOVA was used for all efficacy endpoints, except for change in bilateral polyp grade score, for which baseline polyp grade was added as a covariate.
RESULTS: Compared with placebo, MFNS 200 mug administered once or twice daily produced significantly greater reductions in bilateral polyp grade score (P < .001, P = .010, respectively) and congestion/obstruction (P = .001, P < .001), as well as improvement in loss of smell (P < .001, P = .036), anterior rhinorrhea (P < .001 for both), and postnasal drip (P < .001, P = .001) over month 1. MFNS 200 mug twice daily was superior to MFNS 200 mug once daily in reducing congestion/obstruction (P = .039), and there were more improvers in the MFNS 200 mug twice daily group (P = .035). MFNS was well tolerated in both groups. CONCLUSION: MFNS 200 mug, once or twice daily, was safe and significantly superior to placebo in reducing polyp grade (size and extent) and improving congestion/obstruction and return of sense of smell. MFNS is an effective medical treatment for nasal polyposis and may reduce or delay the need for surgery.
Technorati Tags: Fade Medication; Fade Otorhinolaryngologic Diseases and Disorders
Becker MA , et al. Febuxostat Compared with Allopurinol in Patients with Hyperuricemia and Gout. N Engl J Med 2005 Dec 8;353(23):2450-2461
BACKGROUND: Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase, is a potential alternative to allopurinol for patients with hyperuricemia and gout.
METHODS: We randomly assigned 762 patients with gout and with serum urate concentrations of at least 8.0 mg per deciliter (480 micromol per liter) to receive either febuxostat (80 mg or 120 mg) or allopurinol (300 mg) once daily for 52 weeks; 760 received the study drug. Prophylaxis against gout flares with naproxen or colchicine was provided during weeks 1 through 8. The primary end point was a serum urate concentration of less than 6.0 mg per deciliter (360 micromol per liter) at the last three monthly measurements. The secondary end points included reduction in the incidence of gout flares and in tophus area.
RESULTS: The primary end point was reached in 53 percent of patients receiving 80 mg of febuxostat, 62 percent of those receiving 120 mg of febuxostat, and 21 percent of those receiving allopurinol (P<0.001 p="0.99" p="0.23" p="0.08" p="0.16" p="0.003)" p="0.31" style="font-weight: bold;">CONCLUSIONS: Febuxostat, at a daily dose of 80 mg or 120 mg, was more effective than allopurinol at the commonly used fixed daily dose of 300 mg in lowering serum urate. Similar reductions in gout flares and tophus area occurred in all treatment groups.
Technorati Tags: Fade Medication; Fade Gout
Stelmach R, et al. Effect of Treating Allergic Rhinitis With Corticosteroids in Patients With Mild-to-Moderate Persistent Asthma. Chest 2005 Nov;128(5):3140-7
STUDY OBJECTIVES: Rhinitis and asthma are considered to be synchronic or sequential forms of the same allergic syndrome. Treating the inflammation associated with allergic rhinitis influences the control of asthma. However, few studies have investigated the effect of treating perennial rhinitis on persistent asthma and vice versa. We determined the effects of inhaled or topical nasal beclomethasone dipropionate (BDP) administered separately or in combination on the control of asthma and bronchial hyperresponsiveness (BHR) in patients with the rhinitis/asthma association.
DESIGN: A double-blind, parallel, three-group study.
SETTING: Outpatient clinic of Pulmonary Division/Heart Institute (InCor) and the Division of General Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil.
PATIENTS: Seventy-four patients with mild-to-moderate asthma and allergic rhinitis (median age, 25 years).
INTERVENTIONS: Patients received nasal or inhaled BDP separately or in combination for 16 weeks after a 2-week placebo run-in period.
MEASUREMENTS AND RESULTS: Nasal and pulmonary symptoms, as well as pulmonary function and BHR, were compared among the three groups after 4 weeks and 16 weeks of treatment. Patients in all three groups demonstrated a progressive and significant decrease in nasal and pulmonary symptoms, which started after 4 weeks (p < style="font-weight: bold;">CONCLUSIONS: Failure to consider treatment of rhinitis as essential to asthma management might impair clinical control of asthma. Furthermore, these data suggest that asthma and rhinitis in some patients can be controlled by the exclusive use of nasal medication.
Technorati Tags: Fade Hypersensitivity; Fade Asthma
Latest Questions to the Primary Care Question Answering Service
ASSESSMENT AND DIAGNOSIS
In Alcoholic Cardiomyopathy how is the diagnosis made, and what is the pathophysiology and treatment of this condition?
Assessment; Pathophysiology; Diagnosis
We are wondering if we should buy a pulse oximeter for the practice. Would doing pulse oximetry make our hospital admissions more appropriate for children and adults with chest problems.
Assessment; Admissions; Diagnosis
How long is mump contagious for and what is the risk of infection to a new born baby whose mother may not be immune?
Assessment; MMR; Diagnosis
Should routine monitoring of LFT be done on someone on Minocycline and if so how often?
Assessment; Diagnosis
What is the evidence that a chest xray is useful in a well 8 yr old child with a mild cough and intermittent fever for 5 days?
Assessment; X Ray; Diagnosis
Are their any guidelines on who should be screened for cholesterol?
Assessment; Screening; Diagnosis
Should a patient with atypical chest pains with a positive exercise ECG but normal coronary artery angiography be treated as having ischaemic heart disease - ie given secondary preventive measures etc?
Assessment; Coronary Diseases and Disorders; Diagnosis
My practice is thinking about introducing a blanket screen on all patients over 25 for cholesterol and blood sugar testing. Is there any evidence to suggest that this is effective
Assessment; Screening; Diagnosis
How should a 24hr blood pressure recording be interpreted?. I take the average to be blood pressure reading to be the one I need to respond to. Is this right?
Assessment; Hypertension; Diagnosis; Blood Monitoring
What is the best evidence for an annual U&E check in patients on digoxin therapy? (BNF says should be monitored but states no time frame)
Assessment; Treatment; Diagnosis
Is there a list of drugs showing which monitoring tests should be done how often in patients on them long term eg liver function tests in people on statins etc
Assessment; Drug Administration; Diagnosis
CANCER
What is the evidence for various treatments for prevention of recurrence of breast cancer?
Assessment; Cancer; Diagnosis; Treatment
CARDIOVASCULAR DISORDERS
Whats the incidence of a)dreaming b)nightmares c)disturbed sleep on simvastatin, atorvastatin, pravastatin and rosuvastatin?
Cardiovascular Diseases and Disorders; Diagnosis
Someone is on atenolol 50 mg for hypertension. The BP is going up. Will doubling the dose be more effective or simply have little effect but increase side effects? What is the dose response curve like?
Drug Administration; Hypertension
Simvastatin10 mg nocte in a Type 2 diabetic causes nightmares. Which statin is better?
Drug Administration
What is the evidence for using ACE I's as opposed to ACE II's and what are the specific circumstances in which ACE II's would ever be preferential? (Particular reference to hypertension or heart failure)
Cardiovascular Diseases and Disorders; Hypertension
In patients taking warfarin who need cholesterol lowering, is one statin preferred over another. Are there any specific guidelines about starting statins in patients with warfarin (I am aware that statins can potentiate the effect of warfarin).
Drug Administration
NUTRITION AND METABOLIC DISEASES
P-any, Invervention- Corticosteriod eg prednisolone, short term (30-60mg),one off and repeated doses O- psychiatic, bone- oesteoporosis ie, What are the short and long term implications of one off or repeated doses of short term oral corticosteriods?
Drug Administration; Nutrition
CAUSES, RISKS AND PREVENTION
Following on from your query on delayed antibiotic prescription. My practice is keen to start a delayed prescription service. Do you have any practice policies on implementing delayed prescriptions ?
Drug Administration; Prescription Writing
What is recommended to treat post natal depression in a mother who is breast feeding?
Drug Administration; Treatment; Depression; Breast Feeding
Is being morbidly obese (BMI >40) related to non-specific bladder flow symptoms in otherwise healthy men?
Urologic Diseases and Disorders; Obesity
Is it safe to continue the use of oxytetracycline for longer than 2 years and/or indefinitely for the treatment of skin conditions (such as rosacea) in patients who are otherwise fit and well, and if so what are the complications to be aware of?
Dermatological Diseases and Disorders; Drug Administration; Treatment
Hitting the Headlines - Evidence Behind the Press Stories
Yoga and chronic low back pain
Yoga may be a more effective way to treat chronic low back pain compared to conventional exercise, reported The Times (20 December 2005). However, the well-conducted trial actually found that yoga was more effective than a self-help manual, and not better than conventional exercise as reported by the newspaper.
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The Times (20 December 05) reported that people who suffer from back pain recover faster, have fewer debilitating symptoms and improved functional ability when treated with yoga instead of conventional exercise.
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The report was based on a randomised controlled trial (RCT) comparing 12 weekly sessions of yoga or conventional exercise or a self-help manual. The study found that, after 12 and 26 weeks, yoga was associated with significant improvements in back function and symptoms compared with a self-help manual. Some differences were also found between yoga and conventional exercise, but these were either not statistically significant or not clinically meaningful.
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The newspaper reporting of the study ignored the comparison of yoga with a self-help book and overemphasised the importance of the one statistically significant difference found between yoga and conventional exercise, which was not found to be of clinical importance. In addition, newspaper says that people who did yoga were better at activities that put pressure on their back and took fewer pain killers; these are not specifically reported as results of the research study. Finally, the study did not assess speed of recovery, as suggested by the newspaper report.
Evaluation of the evidence base for yoga and back pain
Where does the evidence come from?
The research was conducted Dr Sherman and Colleagues at the Centre for Health Studies, Group Health Cooperative based in Seattle, USA. The study was funded by the National Centre for Complementary and Alternative Medicine and the National Institute for Arthritis and Musculoskeletal and Skin Disease.
What were the authors' objectives?
To determine whether yoga is more effective than conventional therapeutic exercise or a self-care book for patients with chronic low back pain.
What was the nature of the evidence?
The evidence comes from a randomised controlled trial (RCT) of 26 week duration that included 101 adults with chronic low back pain. People with back pain that was complicated or attributable to an underlying disease, or those with minimal back pain were excluded.
What interventions were examined in the research?
Participants were randomised to receive either 12 weekly 75-minute sessions of yoga or conventional therapeutic exercise classes or received a self-help manual. The yoga and exercise sessions were specifically developed for those with low-back pain and participants in the trial were asked to practise daily at home.
The outcomes of interest were back-related function according to the Roland Disability Scale and rating of how 'bothersome' back pain was. Assessment was made by conducting telephone interviews at six, 12 and 26 weeks to determine back-related dysfunction and symptoms.
What were the findings?
At 12 weeks, yoga was associated with significant improvements in back function compared with conventional exercise and with the self-help manual. However, the difference between yoga and exercise was not clinically meaningful. No difference was found between conventional exercise and the self-help manual.
At 26 weeks, yoga was associated with significant improvements in back function compared with the self-help manual. No significant difference was found between yoga and exercise.
Symptoms decreased in all treatment groups over the duration of the study, although between 12 and 26 months symptom improvement was only observed in the yoga group. Medication use decreased most in the yoga group.
What were the authors' conclusions?
The authors concluded that yoga was more effective than a self-care book in the improvement of function and reducing chronic low back pain, with the benefits lasting for several months.
How reliable are the conclusions?
On the whole, this was a relatively well-conducted study. The authors clearly stated the aims of the research and the methods used in the design, conduct and analysis were appropriate. Although the participants could not be blinded to the treatment they were receiving, the interviewers who recorded the response to treatment did not know which treatment a participant had received. Attendance at yoga and exercise sessions was high and the majority of participants were contacted for follow-up. However, the use of telephone interviews to determine the effectivness of the interventions may have reduced the accuracy of the reporting of the outcomes, although this did ensure a high follow-up rate. It should also be noted that more participants assigned to the yoga group reported yoga as their preferred treatment, and perceived expectations of yoga and exercise were higher than for the self-help book. Collectively, these factors may have influenced the reliability of the results.
When interpreting the results of this study more generally, it should be noted that the yoga and exercise classes evaluated were specifically developed for this population, and were delivered by trained instructors. The benefits or harms of other types of yoga regimens cannot be extrapolated from this study. In addition, the results of the study may only apply to a specific population, as most of those studied were women who were well-educated with functional ability.
Systematic reviews
Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.
There were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR) or on the Database of Abstracts of Reviews of Effects (DARE).
References and resources
1. Yoga gives hope to back pain sufferers. The Times, 20 December 2005, p8.
Consumer information
The British Wheel of Yoga
Mass Media; Yoga; Back Pain
'Young girls respond better to cancer vaccine'
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Three newspapers (19 December 2005) reported the results of a study of the vaccine Cervarix in adolescents and young women (1-3). The newspapers reported that the response to the vaccine was greater in girls aged 10 to 14 years than in those aged 15 to 25 years.
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The newspaper articles appear to be based on an abstract of a conference presentation given at the 45th Interscience Conference on Antimicrobial Agents and Chemotherapy (4). The study assessed the immune response and safety of a vaccine developed to protect against the cancer-causing Human Papilloma virus (HPV) types 16/18 in 158 adolescent girls (aged 10 to 14 years) and 458 young women (aged 15 to 25 years). The study found that an immune response was achieved in 100% of participants, but it was twice as high in those aged 10 to 14 years. The abstract reports that the vaccine was well tolerated and adverse events were similar for both groups. The vaccine has not yet been submitted for approval by regulatory bodies.
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The newspaper reports were generally accurate summaries of the results described in the conference abstract. It is not possible to comment on the quality of the research or the reliability of the findings as the abstract provides insufficient detail.
Systematic reviews
Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.
There were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR) or on the Database of Abstracts of Reviews of Effects (DARE).
References and resources
1. Young girls respond better to cancer vaccine. The Independent, 19 December 2005, p20.
2. Cervical jab for under 11's. Daily Telegraph, 19 December 2005, p10.
3. Younger girls in line for cervical cancer vaccine. The Guardian, 19 December 2005, p8.
Consumer information
CancerBACUP: Cervical cancer information centre
NHS Direct: Cancer of the cervix
Previous Hitting the Headlines summaries on this topic
'Vaccine for cervical cancer'. Hitting the Headlines archive, 7 October 2005.
Cervical cancer vaccine 'in two years'. Hitting the Headlines archive, 7 April 2005.
'Vaccine for cervical cancer'. Hitting the Headlines archive, 2 February 2005.
'Vaccine hope over cervical cancer'. Hitting the Headlines archive, 12 November 2004.
'Vaccine to beat cervical cancer' Hitting the Headlines archive, 29 October 2004.
A vaccine for cervical cancer? Hitting the Headlines archive, 20-21 November 2002.
Cervical Cancer; Vaccination
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