Post 19: 17th February 2006
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
Latest Guidelines
NICE (2006) Postnatal care: second consultation. London: NICE.
A clinical practice guideline on postnatal care is being developed for use in the NHS in England and Wales. Registered stakeholders for the postnatal care guideline are invited to comment on the provisional guideline recommendations.
Department of Health (2006) National Guidelines for Maternity Services Liaison Committees (MSLCs). London: DoH.
These guidelines are for healthcare managers, commissioners, practitioners and others. They provide advice on making local MSLCs work more effectively. They include practice examples and reference details to enable local initiatives to build on the experience of other groups, together with self-assessment tools and detailed guidance on establishing a Committee and making it effective.
Latest Reports
John Appleby and Anthony Harrison (2006)Spending on Healthcare: How much is enough?. London: King's Fund.
Investment in the NHS has increased significantly under the Blair government. Spending will soon reach the EU average, but when we catch up with our European neighbours, what then? Assuming that pressures to spend more will continue, but that marginal health returns on extra investment are likely to diminish, this paper asks the question: how much is enough? In particular, can a limit on health spending be defined, and if so, how? And what evidence is required to inform what is ultimately a political decision?
NHS Confederation (2006) Our health, our care, our say: A new direction for community services. NHS Confederation Briefing Issue 128.
The Government’s white paper on community health and care services – Our health, our care, our say – was launched at the end of January. Drawn up after a consultation process which involved more than 143,000 people, it promises a shift in strategic direction for health services. Over the next five years patients will be able to
expect more joined-up and personalised care delivered in the community or at their homes, if appropriate. This Briefing looks at some of the key policies, as outlined in the white paper, and what they will mean for the health service.
Department of Health (2006) The NHS in England: the operating framework for 2006/7. London: DoH.
This document, addressed to all NHS Chief Executives, sets out the specific business and financial arrangements for the NHS for 2006/7. It describes, amongst other things, the delivery priorities, the payment by results and tariff details and expectations on the development of choice, commissioning and practice-based commissioning. It gives new SHAs the influence to ensure local implementation of the guidance.
Department of Health (2006) ISTC Manual Independent Sector Treatment Centre (ISTC) Programme. London: DoH.
The Independent Sector Treatment Centre (ISTC) Programme is part of a major initiative to create additional capacity within the NHS to reduce waiting times and introduce choice for patients. The purpose of this manual is to explain the background to Wave 1 of the ISTC Programme, the key issues relating to it and the ways in which Wave 1 works in practice.
Lisa Dyson, Mary Renfrew, Alison McFadden, Felicia McCormick, Gill Herbert and James Thomas (2006) Effective action briefing on the initiation and duration of breastfeeding: Effective action recommendations. York: University of York.
The effective action briefing on the initiation and duration of breastfeeding presents draft evidence-based recommendations for promoting the initiation and continuation of breastfeeding, particularly among population groups where breastfeeding rates are low. The report also describes the characteristics of effective programmes for these groups and for different settings as well as strategies for overcoming barriers to change.
Glickman, M., Corbin. T., Tortoriello, M. and Devis, T. (2006) United Kingdom health statistics. London: ONS.
These key indicators are among a wide range of statistics that show noticeable variations in health across the four countries of the UK.
Evidence from Journals
Alper BS, White DS, Ge B. (2005) Physicians answer more clinical questions and change clinical decisions more often with synthesized evidence: a randomized trial in primary care. Ann Fam Med. Nov-Dec;3(6):507-13.
PURPOSE: Clinicians need evidence in a format that rapidly answers their questions. DynaMed is a database of synthesized evidence. We investigated whether primary care clinicians would answer more clinical questions, change clinical decision making, and alter search time using DynaMed in addition to their usual information sources.
METHODS: Fifty-two primary care clinicians naive to DynaMed searched for answers to 698 of their own clinical questions using the Internet. On a per-question basis, participants were randomized to have access to DynaMed (A) or not (N) in addition to their usual information sources. Outcomes included proportions of questions answered, proportions of questions with answers that changed clinical decision making, and median search times. The statistical approach of per-participant analyses of clinicians who asked questions in both A and N states was decided before data collection.
RESULTS: Among 46 clinicians in per-participant analyses, 23 (50%) answered a greater proportion of questions during A than N, and 13 (28.3%) answered more questions during N than A (P = .05). Finding answers that changed clinical decision making occurred more often during A (25 clinicians, 54.3%) than during N (13 clinicians, 28.3%) (P = .01). Search times did not differ significantly. Overall, participants found answers for 263 (75.8%) of 347 A questions and 250 (71.2%) of 351 N questions. Answers changed clinical decision making for 224 (64.6%) of the A questions and 209 (59.5%) of the N questions. CONCLUSIONS: Using DynaMed, primary care clinicians answered more questions and changed clinical decisions more often, without increasing overall search time. Synthesizing results of systematic evidence surveillance is a feasible method for meeting clinical information needs in primary care.
Janosky JE (2005) Use of the single subject design for practice based primary care research. Postgrad Med J. 2005 Sep;81(959):549-51.
The use of a single subject research design is proposed for practice based primary care research. An overview of the rationale of the design, an introduction to the methodology, strengths, limitations, a sample of recent literature citations, a working example, and possible clinical applications are presented.
Arroll B, Macgillivray S, Ogston S, Reid I, Sullivan F, Williams B, Crombie I. (2005) Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: a meta-analysis. Ann Fam Med. Sep-Oct;3(5):449-56.
PURPOSE: Depression is common in primary care. There are no systematic reviews of depression treatment comparing antidepressants with placebo; hence, we do not know whether these medications are effective in primary care.
METHODS: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Group register of controlled trials, MEDLINE, International Pharmaceutical abstracts, PsycINFO, and EMBASE. Abstracts of potential studies were reviewed independently by 2 authors. Studies needed to include randomized controlled trials of either a tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitor (SSRI), or both, and placebo in a primary care setting. The data and quality of the studies were extracted and assessed by 2 authors blind to the other's choice. Disagreements were resolved by discussion. The main outcome measures were the standardized mean difference and weighted mean difference of the final mean depression scores, the relative risk of improvement, and the number withdrawing because of side effects. Pooling of results was done using Review Manager 4.2.2.
RESULTS: There were 10 studies in which TCAs were compared with placebo, 3 in which SSRIs were compared with placebo, and 2 with both compared with placebo. One half of the studies were of low methodological quality, and nearly all studies were of short duration, typically 6 to 8 weeks. Pooled estimates of efficacy data showed a relative risk of 1.26 (95% CI, 1.12-1.42) for improvement with TCAs compared with placebo; For SSRIs, relative risk was 1.37 (95% CI, 1.21-1.55). Most patients, 56% to 60%, responded well to active treatment compared with 42% to 47% for placebo. The number needed to treat for TCAs was about 4, and for SSRIs it was 6. The numbers needed to harm (for withdrawal caused by side effects) ranged from 5 to 11 for TCAs and 21 to 94 for SSRIs. Low-dose (100 mg or 75 mg) as well as high-dose TCAs were effective.
CONCLUSION: This systematic review is the first comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the first to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clinical activity than prescribing placebo.
Wilson, E.C.F., Rees, J. and Fordham, R.J. (2006) Developing a prioritisation framework in an English Primary Care Trust. Cost Effectiveness and Resource Allocation 2006, 4:3
Background : In the English NHS, Primary Care Trusts (PCTs) are required to commission health services, to maximise the well-being of the population, subject to the available budget. There are numerous techniques employed to make decisions, some more rational and transparent than others. A weighted benefit score can be used to rank options but this does not take into account value for money from investments.
Methods: We developed a weighted benefit score framework for use in an English PCT which ranked options in order of 'cost-value' or 'cost per point of benefit'. Our method differs from existing techniques by explicitly combining cost and a composite weighted benefit score into the cost-value ratio.
Results: The technique proved readily workable, and was able to accommodate a wide variety of data and competing criteria. Participants felt able to assign scores to proposed services, and generate a ranked list, which provides a solid starting point for the PCT Board to discuss and make funding decisions. Limitations included potential for criteria to be neither exhaustive nor mutually exclusive and the lack of an interval property in the benefit score limiting the usefulness of a cost-value ratio.
Conclusions: A technical approach to decision making is insufficient for making prioritisation decisions, however our technique provides a very valuable, structured and informed starting point for PCT decision making.
Dr Foster Intelligence (2006) Keeping people out of hospital : the challenge of reducing emergency admissions. London: Dr Foster Intelligence.
According to the report more than one million emergency admissions every year, via accident and emergency, could be better managed outside hospital - at home or in the community. The findings are based on the first ever analysis of national hospital data to identify the impact of repeat emergency hospital admissions on the NHS, by patients referred to as high-impact users - those who are admitted to accident and emergency at least three times in a year. The report also reveals that there is wide geographical variation in the number of emergency admissions by high-impact users, from fewer than 1,000 in one south east primary care trust to nearly 10,000 in a primary care trust in the Midlands.
Beresford SA, Johnson KC, Ritenbaugh C, Lasser NL, Snetselaar LG, Black HR, Anderson GL, Assaf AR, Bassford T, Bowen D, Brunner RL, Brzyski RG, Caan B, Chlebowski RT, Gass M, Harrigan RC, Hays J, Heber D, Heiss G, Hendrix SL, Howard BV, Hsia J, Hubbell FA, Jackson RD, Kotchen JM, Kuller LH, LaCroix AZ, Lane DS, Langer RD, Lewis CE, Manson JE, Margolis KL, Mossavar-Rahmani Y, Ockene JK, Parker LM, Perri MG, Phillips L, Prentice RL, Robbins J, Rossouw JE, Sarto GE, Stefanick ML, Van Horn L, Vitolins MZ, Wactawski-Wende J, Wallace RB, Whitlock E. (2006) Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. Feb 8;295(6):643-54.
CONTEXT: Observational studies and polyp recurrence trials are not conclusive regarding the effects of a low-fat dietary pattern on risk of colorectal cancer, necessitating a primary prevention trial. OBJECTIVE: To evaluate the effects of a low-fat eating pattern on risk of colorectal cancer in postmenopausal women.
DESIGN, SETTING, AND PARTICIPANTS: The Women's Health Initiative Dietary Modification Trial, a randomized controlled trial conducted in 48,835 postmenopausal women aged 50 to 79 years recruited between 1993 and 1998 from 40 clinical centers throughout the United States.
INTERVENTIONS: Participants were randomly assigned to the dietary modification intervention (n = 19,541; 40%) or the comparison group (n = 29,294; 60%).The intensive behavioral modification program aimed to motivate and support reductions in dietary fat, to increase consumption of vegetables and fruits, and to increase grain servings by using group sessions, self-monitoring techniques, and other tailored and targeted strategies. Women in the comparison group continued their usual eating pattern.
MAIN OUTCOME MEASURE: Invasive colorectal cancer incidence.
RESULTS: A total of 480 incident cases of invasive colorectal cancer occurred during a mean follow-up of 8.1 (SD, 1.7) years. Intervention group participants significantly reduced their percentage of energy from fat by 10.7% more than did the comparison group at 1 year, and this difference between groups was mostly maintained (8.1% at year 6). Statistically significant increases in vegetable, fruit, and grain servings were also made. Despite these dietary changes, there was no evidence that the intervention reduced the risk of invasive colorectal cancer during the follow-up period. There were 201 women with invasive colorectal cancer (0.13% per year) in the intervention group and 279 (0.12% per year) in the comparison group (hazard ratio, 1.08; 95% confidence interval, 0.90-1.29). Secondary analyses suggested potential interactions with baseline aspirin use and combined estrogen-progestin use status (P = .01 for each). Colorectal examination rates, although not protocol defined, were comparable between the intervention and comparison groups. Similar results were seen in analyses adjusting for adherence to the intervention.
CONCLUSION: In this study, a low-fat dietary pattern intervention did not reduce the risk of colorectal cancer in postmenopausal women during 8.1 years of follow-up.
Howard BV, Van Horn L, Hsia J, Manson JE, Stefanick ML, Wassertheil-Smoller S, Kuller LH, LaCroix AZ, Langer RD, Lasser NL, Lewis CE, Limacher MC, Margolis KL, Mysiw WJ, Ockene JK, Parker LM, Perri MG, Phillips L, Prentice RL, Robbins J, Rossouw JE, Sarto GE, Schatz IJ, Snetselaar LG, Stevens VJ, Tinker LF, Trevisan M, Vitolins MZ, Anderson GL, Assaf AR, Bassford T, Beresford SA, Black HR, Brunner RL, Brzyski RG, Caan B, Chlebowski RT, Gass M, Granek I, Greenland P, Hays J, Heber D, Heiss G, Hendrix SL, Hubbell FA, Johnson KC, Kotchen JM. (2006) Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. Feb 8;295(6):693-5.
CONTEXT: Multiple epidemiologic studies and some trials have linked diet with cardiovascular disease (CVD) prevention, but long-term intervention data are needed.
OBJECTIVE: To test the hypothesis that a dietary intervention, intended to be low in fat and high in vegetables, fruits, and grains to reduce cancer, would reduce CVD risk.
DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of 48,835 postmenopausal women aged 50 to 79 years, of diverse backgrounds and ethnicities, who participated in the Women's Health Initiative Dietary Modification Trial. Women were randomly assigned to an intervention (19,541 [40%]) or comparison group (29,294 [60%]) in a free-living setting. Study enrollment occurred between 1993 and 1998 in 40 US clinical centers; mean follow-up in this analysis was 8.1 years.
INTERVENTION: Intensive behavior modification in group and individual sessions designed to reduce total fat intake to 20% of calories and increase intakes of vegetables/fruits to 5 servings/d and grains to at least 6 servings/d. The comparison group received diet-related education materials.
MAIN OUTCOME MEASURES: Fatal and nonfatal coronary heart disease (CHD), fatal and nonfatal stroke, and CVD (composite of CHD and stroke).
RESULTS: By year 6, mean fat intake decreased by 8.2% of energy intake in the intervention vs the comparison group, with small decreases in saturated (2.9%), monounsaturated (3.3%), and polyunsaturated (1.5%) fat; increases occurred in intakes of vegetables/fruits (1.1 servings/d) and grains (0.5 serving/d). Low-density lipoprotein cholesterol levels, diastolic blood pressure, and factor VIIc levels were significantly reduced by 3.55 mg/dL, 0.31 mm Hg, and 4.29%, respectively; levels of high-density lipoprotein cholesterol, triglycerides, glucose, and insulin did not significantly differ in the intervention vs comparison groups. The numbers who developed CHD, stroke, and CVD (annualized incidence rates) were 1000 (0.63%), 434 (0.28%), and 1357 (0.86%) in the intervention and 1549 (0.65%), 642 (0.27%), and 2088 (0.88%) in the comparison group. The diet had no significant effects on incidence of CHD (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.90-1.06), stroke (HR, 1.02; 95% CI, 0.90-1.15), or CVD (HR, 0.98; 95% CI, 0.92-1.05). Excluding participants with baseline CVD (3.4%), the HRs (95% CIs) for CHD and stroke were 0.94 (0.86-1.02) and 1.02 (0.90-1.17), respectively. Trends toward greater reductions in CHD risk were observed in those with lower intakes of saturated fat or trans fat or higher intakes of vegetables/fruits.
CONCLUSIONS: Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk factors, suggesting that more focused diet and lifestyle interventions may be needed to improve risk factors and reduce CVD risk.
Videoconferencing enables improved healthcare for cancer patients. Br J of Healthcare Computing & Information Management 2006;23(1) p31.
This case study looks at the videoconferencing system used by the Surrey, West Sussex and Hampshire (SWSH) Cancer Network. A shortage of cancer specialists and palliative care professionals led to the install of the system which is used to maximise the availablility of expert resource for patient treatment and reduce the necessity for travel.
Reisinger KS, Brown ML, Xu J, Sullivan BJ, Marshall GS, Nauert B, Matson DO, Silas PE, Schodel F, Gress JO, Kuter BJ (2006) A combination measles, mumps, rubella, and varicella vaccine (ProQuad) given to 4- to 6-year-old healthy children vaccinated previously with M-M-RII and Varivax. Pediatrics. Feb;117(2):265-72.
BACKGROUND: In the United States, children receive primary doses of M-M-RII (Merck & Co, Inc, West Point, PA) and Varivax (Merck & Co, Inc) beginning at 12 months, often at the same health care visit. Currently a second dose of M-M-RII is given to 4- to 6-year-old children, to increase vaccination rates and to reduce the number of individuals without detectable antibodies. A second dose of a varicella-containing vaccine may result in similar benefits.
OBJECTIVES: To demonstrate that ProQuad (measles, mumps, rubella, and varicella virus vaccine live; Merck & Co, Inc) may be given in place of a second dose of M-M-RII or second doses of M-M-RII and Varivax for 4- to 6-year-old children.
METHODS: Four- to 6-year-old children who had been immunized previously with M-M-RII and Varivax were assigned randomly to receive either ProQuad and placebo (N = 399), M-M-RII and placebo (N = 195), or M-M-RII and Varivax (N = 205) and were then monitored for safety and immunogenicity.
RESULTS: ProQuad was generally well tolerated. Similarity (noninferiority) was demonstrated in postvaccination antibody responses to measles, mumps, and rubella between recipients of ProQuad and all recipients of M-M-RII and in responses to varicella between recipients of ProQuad and recipients of Varivax. Postvaccination seropositivity rates for antibodies against all 4 viruses were nearly 100% in all 3 groups. Small fold increases were observed for measles, mumps, and rubella antibody titers. In contrast, substantial boosts in varicella antibody titers were observed among recipients of a second dose of varicella vaccine, administered as ProQuad or Varivax.
CONCLUSIONS: ProQuad may be used in place of a second dose of M-M-RII or second doses of M-M-RII and Varivax for 4- to 6-year-old children
Francavilla R, Lionetti E, Castellaneta SP, Magista AM, Boscarelli G, Piscitelli D, Amoruso A, Di Leo A, Miniello VL, Francavilla A, Cavallo L, Ierardi E. (2005) Improved efficacy of 10-Day sequential treatment for Helicobacter pylori eradication in children: a randomized trial. Gastroenterology. Nov;129(5):1414-9.
BACKGROUND & AIMS: The currently recommended first-line eradication treatment of Helicobacter pylori in children is usually successful in about 75%. Recently, in adults, a novel 10-day sequential treatment has achieved an eradication rate of 95%. The aim of the study was to assess the H pylori eradication rate of the sequential treatment regimen compared with conventional triple therapy in children.
METHODS: Seventy-eight consecutive children with H pylori infection were randomized to receive either sequential treatment (omeprazole plus amoxicillin for 5 days, followed by omeprazole plus clarithromycin plus tinidazole for another 5 days) (n = 38; 15 boys [39.5%]; median age, 11.0 years [range, 3.3-16 years]) or triple therapy (omeprazole, amoxicillin, and metronidazole) for 1 week (n = 37; 15 boys [40.5%]; median age, 9.9 years [range, 4.3-16 years]). H pylori infection was based on 2 out of 3 positive tests results: 13C-urea breath test, rapid urease test, and histologic analysis. Eradication was assessed by 13C-urea breath test 8 weeks after therapy.
RESULTS: Seventy-four patients completed the study. H pylori eradication was achieved in 36 children receiving sequential treatment (97.3%; 95% confidence interval, 86.2-99.5) and 28 children receiving triple therapy (75.7%; 95% confidence interval, 59.8-86.7) (P < .02). Compliance with therapy was good (>95%) in all.
CONCLUSIONS: Our study shows, for the first time in children, that 10-day sequential treatment achieves a higher eradication rate than standard triple therapy, which is consistent with the results of adult studies.
Therapeutics
Trimethoprim reduced dysuria in women with symptoms of urinary tract infection but...
Leibovici
Evid Based Med.2006; 11: 19
Topical chloramphenicol was not effective in children with acute infective conjunctivitis
Lindbaek
Evid Based Med.2006; 11: 18
The Bug Buster kit was better than single dose pediculicides for head lice
Dawes
Evid Based Med.2006; 11: 17
Review: some evidence shows that self help books based on cognitive behaviour therapy...Primack
Evid Based Med.2006; 11: 8
Review: limited evidence from 2 randomised controlled trials suggests that oral...
Bial
Evid Based Med.2006; 11: 9
Review: cholinesterase inhibitors may be effective in Alzheimer’s disease
Luckmann
Evid Based Med.2006; 11: 23
Review: anticholinergics in addition to ß2 agonists improve outcome in children...
Thien
Evid Based Med.2006; 11: 21
Pulmonary vein isolation was better than antiarrhythmic drugs for symptomatic atrial...
George Wyse
Evid Based Med.2006; 11: 16
Using exhaled NO concentrations to adjust inhaled corticosteroid dose maintained...
Rees
Evid Based Med.2006; 11: 20
Review: vitamin D plus calcium, but not vitamin D alone, prevents osteoporotic fractures...
Johnell
Evid Based Med.2006; 11: 13
Review: viscosupplementation for knee osteoarthritis reduces pain and improves function
Shoor
Evid Based Med.2006; 11: 12
Review: angiotensin converting enzyme inhibitors and angiotensin receptor blockers...
Karthikeyan and Lip
Evid Based Med.2006; 11: 15
Adjunctive treatment with eplerenone reduced 30 day all cause mortality in acute...
Moyer and Berger
Evid Based Med.2006; 11: 14
Diagnosis
Review: IgA endomyseal and transglutaminase antibodies had high specificity for...
Gibson
Evid Based Med.2006; 11: 25
Multislice computed tomography detected coronary artery disease
Hlatky and Sanders Evid Based Med.2006; 11: 24
Clinical Prediction Guide
A simple risk score predicted 7 day stroke risk after transient ischaemic attack
Hart
Evid Based Med.2006; 11: 27
Trials
Latest Questions to the Primary Care Question Answering Service
ASSESSMENT AND DIAGNOSIS
A 79 year old patient has mild lymphocytosis of 8*10 9 cells. Is it appropriate to continue monitoring or should be be referred? Also, since having this raised lymph he has had a CVA - may they be linked?
In which situations can a bisphosphonate be initiated without performing a DEXA scan?
I need to obtain current UK centile / BMI charts for children and young adults.Can I get printables from net?
What is the latest view on the most appropriate injection site for intramuscular injections?
What features help distinguish flu from the common cold, and how reliable are they at discriminating?
If notes say total abdominal hysterectomy with any histology can we assume that cervix was removed?
How useful is the D-dimer test in diagnosing DVT?
I have a patient who had had long irregular periods since menarche at 13yrs, what is the best treatment option?
Are their any recent guidelines discussing investigation and treatment of erectile dysfunction?
What is the effect of HRT on fibroids?
What investigations are needed in a man who has had 2 proven UTIs in 6 months?
Is there any evidence that Bell's Palsy can resolve within 24 – 48 hours?
What is the significance of ventricular ectopic beats and supra ventricular ectopic beats in a 24 hour ecg. Is there any significance of bigeminy or trigeminy?
1) Is there any evidence of benefit of using pulse oximeters in the assessment of patients with respiratory disorders (Pleuritic chest pains, asthma) in the general practice setting? 2) Also any evidence of positive or negative predictive values of normal and abnormal oxygen levels (detected by pulse oximetry) in disorders such as Pulm embolism etc?
CARDIOVASCULAR DISEASE
How soon after first CVA should prophylactic aspirin be introduced?
What are the risks of using Dianette as an oral contraceptive, over and above the risks associated with a 3rd generation oral contraceptive pill?
If a patient on atenolol 50mg daily has the dose increased to 100mg daily, can the additional risk in terms of metabolic side effects be quantified i.e. diabetogenic effects - particularly if also taking thiazides?
CAUSES, RISKS AND PREVENTION
Is there any evidence that use of zoladex injections used for 6 months for treatment of endometriosis can affect future fertility in a detrimental way?
It is quoted that 20-30% of consultations in primary care is due to musculoskeletal problems. What references are there, in British literature?
By the age of 25, what vaccinations should everyone have had / been offered as a minimum?
Someone, now 19 has had one Meningococcal C vaccine as a child and one acwy vaccine 4 years ago. Should they have another menC now on going to university?
Someone aged 30 is going to university. Should they have Meningococcal C immunisation? should they have any other vaccinations, assuming they had normal childhood immunisations?
Is vomiting a usual side-effect of trimethoprim in children?
OBESITY
Are there any new NICE or other goverment guidelines about when to start Orlistat in obesity and how long can be taken for? Are there any new revision as predicted by Feb 2004 in the NICE guidelines?
COMPLEMENTARY MEDICINE
Are there any complementary therapies/medicines that have proved helpful in rheumatoid arthritis?
CANCER
Should we be doing cervical smears on virgins?
MUSCULOSKELETAL DISEASES
Is there any published evidence on the effectiveness of steroid injection for coccygodynia? Is surgery effective?
If a patient with osteoporosis is unable to take calcium supplements, are bisphosphonates as effective as when a patient is able to take calcium supplements?
In patients who have carpal tunnel syndrome secondary to hypothyroidism, what is the evidence (if any) to suggests that treatment with thyroxine settles the symptoms of the carpal tunnel syndrome.
Hitting the Headlines - Evidence Behind the Press Stories
New drug for stroke patients
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A new drug, NXY-059, could aid the recovery of stroke patients reported two newspapers on 9 February 2006 (1,2).
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A multinational trial of NXY-059 versus placebo for the reduction of disability after stroke was the basis for the newspaper reports. The results of the trial showed a twenty percent reduced likelihood of disability after being given NXY-059 compared with being given placebo at 90 days following stroke (3). No improvements were found in neurological functioning and ability to perform tasks independently. Mortality and rates of adverse events were similar in the treatment and placebo groups.
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The Sun (1) provided a brief but accurate report of this well-conducted trial. The findings of the trial appear reliable. The Daily Express (2) stated that the new drug increased the chances of survival. However this was not a finding of the trial. Although the headline was overly optimistic in its use of the word 'Miracle', the article did correctly state that the new drug will not be commercially available for some time.
Evaluation of the evidence base for NXY-059 for Acute Ischemic Stroke
Where does the evidence come from?
The evidence comes from the Stroke-Acute Ischemic NXY Treatment (SAINT I) trial and was conducted in 154 hospitals across 24 countries. The research was led by Professor Kennedy R Lees of the Acute Stroke Unit and Cerebrovascular Clinic, University Department of Medicine and Therapeutics, Western Infirmary, Glasgow. The trial was funded by Astra-Zeneca. The academic authors vouch for the veracity and completeness of the data and data analysis.
What were the authors' objectives?
To assess whether the drug NXY-059 would reduce disability in patients following acute ischaemic stroke.
What was the nature of the evidence?
SAINT I was a multicentre randomised double-blind placebo controlled trial. The trial included 1722 patients with acute ischemic stroke. Patients were eligible for inclusion if they were conscious, aged over 18, had a clinical diagnosis of acute stroke, had limb weakness and a score of at least six on the National Institutes of Health Stroke Scale (NIHSS).
What interventions were examined in the research?
Patients were randomised to receive a 72 hour infusion of placebo or intravenous NXY-059 within six hours after the onset of stroke.
The main outcome of interest was disability at 90 days according to the modified Rankin Scale. The scale ranges from 0 (no symptoms) to 5 (severe disability requiring constant care and bedridden). Assessment was made at 24 and 72 hours and at 7, 30 and 90 days. Other outcomes of interest included neurological improvements, measures of independence, mortality and adverse events.
What were the findings?
At 90 days, there was a twenty percent reduced likelihood of disability in those given NXY-059 compared with those given placebo based on the modified Rankin Scale.
No improvements in neurological functioning were noted on the NIHSS or in independence as rated by the Barthel Index. Mortality and rates of serious and non-serious adverse events were similar in the treatment and placebo groups.
What were the authors' conclusions?
The authors concluded that, although NXY-059 administered within six hours of acute ischaemic stroke reduced disability at 90 days according to the modified Rankin scale, further research is needed to determine its potential benefits for stroke patients.
How reliable are the conclusions?
This large multicentre trial appears to have used appropriate methods in its design and analysis, and to have been well conducted. Clear details were given for all participants included in the study indicating that the numbers who withdrew from the trial or were lost to follow-up or received an unassigned treatment were small. The study groups were comparable at baseline. The conclusions are therefore likely to be reliable.
The authors state that a further trial, SAINT II, is under way with the aim of confirming the findings of the present study in a larger sample.
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. Drug bid for stroke. The Sun, 9 February 2006, p15.
2. 'Miracle' drug may save stroke victims. Daily Express, 9 February 2006, p13.
Consumer information
Document of the Week from the National Library for Health
Sharing best practice in quality use of medicine
Report on a tool to facilitate sharing best practice in quality use of medicine BMC Health Services Research reports on an online, web-based project database, known as QUMap, which enables researchers to collaborate on research related to improving the use of medicines. One of the issues that was raised in this research, was that much of the research was carried out for the benefits of the health professionals rather than the consumers, and that frequently, consumers were not involved in the process.
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