Withdrawal from treatment as an outcome in the ISOLDE study of COPD

OBJECTIVES

To investigate the determinants of patient withdrawal from our study, and the effect of these withdrawals on the outcome of treatment with inhaled corticosteroids in patients with COPD.

DESIGN

A double-blind, placebo-controlled, randomized trial.

SETTING

Eighteen outpatient centers in the United Kingdom.

PARTICIPANTS

Seven hundred fifty-one patients with stable COPD defined clinically and as baseline postbronchodilator FEV(1) > or = 0.8 L and < 85% predicted, FEV(1)/FVC ratio < 70%, and FEV(1) change after albuterol < 10% of predicted.

INTERVENTION

Random assignment of either 500 microg bid of inhaled fluticasone propionate (FP) using a spacer device or an identical placebo inhaler. Treatment was continued for 3 years or until patients withdrew from follow-up.

MEASUREMENTS AND RESULTS

Postbronchodilator FEV(1) was measured on three occasions before randomization and every 3 months thereafter. Health status was assessed by the disease-specific St. George Respiratory Questionnaire (SGRQ) and the modified short-form 36 questionnaire (SF-36) at baseline and every 6 months. Three hundred thirty-nine patients withdrew, of whom 156 patients received FP. Prescription of frequent courses of oral prednisolone was the most common reason for withdrawing as specified in the protocol (69 patients in the FP group withdrew due to respiratory symptoms, compared with 93 patients in the placebo group). This explained the significantly greater dropout of placebo-treated patients that was most evident when FEV(1) was < 50% predicted. Patients withdrawing had a significantly more rapid decline in health status, measured by both the SGRQ and the SF-36 (p < 0.001). Those withdrawing from the placebo group had a more rapid decline in FEV(1) and more exacerbations than the FP-treated groups. Baseline FEV(1) was lower in dropouts than in patients completing the study receiving placebo, but there was no difference between the respective groups receiving FP.

CONCLUSIONS

Patients who withdrew from follow-up were those with the most rapidly deteriorating health status and lung function. Losing these patients from the final analysis can reduce the power of a study to achieve its primary end point.

Primary and revision lumbar discectomy. A 16-year review from one centre

We present a review of 553 patients who underwent surgery for intractable sciatica ascribed to prolapsed lumbar intervertebral disc. One surgeon in one institution undertook or supervised all the operations over a period of 16 years. The total number of primary discectomies included in the study was 531, of which 42 subsequently required a second operation for recurrent sciatica, giving a revision rate of 7.9%. Factors associated with reoperation were analysed. A contained disc protrusion was almost three times more likely to need revision surgery, compared with extruded or sequestrated discs. Patients with primary protrusions had a significantly greater straight-leg raise and reduced incidence of positive neurological findings compared with those with extruded or sequestrated discs. These patients should therefore be selected out clinically and treated by a more enthusiastic conservative programme, since they are three times more likely to require revision surgery.

Prednisolone response in patients with chronic obstructive pulmonary disease: results from the ISOLDE study

BACKGROUND

A trial of corticosteroids has been recommended for all patients with chronic obstructive pulmonary disease (COPD), with the subsequent "response" determining the treatment selected. This approach assumes that patients can be reliably divided into responder and non-responder groups. We have assessed whether such a separation is statistically valid, which factors influence the change in forced expiratory volume in 1 second (FEV(1)) after prednisolone, and whether the prednisolone response predicts 3 year changes in FEV(1), health status, or number of exacerbations during placebo or fluticasone propionate treatment.

METHODS

Oral prednisolone 0.6 mg/kg was given for 14 days to 524 patients with COPD before randomised treatment for 3 years with fluticasone propionate or placebo. Factors relating to change in FEV(1) after prednisolone were investigated using multiple regression. The response to prednisolone was entered into separate mixed effects models of decline in FEV(1) and health status during the 3 years of the study.

RESULTS

The post-bronchodilator FEV(1) increased by a mean 60 ml (CI 46 to 74) after prednisolone with a wide unimodal distribution. Current smoking was the factor most strongly associated with the change in FEV(1) after prednisolone, with an increase of 35 ml in current smokers and 74 ml in confirmed ex-smokers (p<0.001). There was no relationship between the change in FEV(1) after prednisolone and the response to inhaled bronchodilators, baseline FEV(1), atopic status, age, or sex. The response to prednisolone, however expressed, was unrelated to the subsequent change in FEV(1) over the following 3 years on either placebo or fluticasone propionate. Regression to the mean effects explained much of the apparent prednisolone response. The significant effect of treatment on decline in health status was not predicted by the prednisolone response.

CONCLUSION

Patients with COPD cannot be separated into discrete groups of corticosteroid responders and non-responders. Current smoking reduces the FEV(1) response to prednisolone. Prednisolone testing is an unreliable predictor of the benefit from inhaled fluticasone propionate in individual patients.

Bronchodilator reversibility testing in chronic obstructive pulmonary disease

BACKGROUND

A limited or absent bronchodilator response is used to classify chronic obstructive pulmonary disease (COPD) and can determine the treatment offered. The reliability of the recommended response criteria and their relationship to disease progression has not been established.

METHODS

660 patients meeting European Respiratory Society (ERS) diagnostic criteria for irreversible COPD were studied. Spirometric parameters were measured on three occasions before and after salbutamol and ipratropium bromide sequentially or in combination over 2 months. Responses were classified using the American Thoracic Society/GOLD (ATS) and ERS criteria. Patients were followed for 3 years with post-bronchodilator FEV(1) and exacerbation history recorded 3 monthly and health status 6 monthly.

RESULTS

FEV(1) increased significantly with each bronchodilator, a response that was normally distributed. Mean post-bronchodilator FEV(1) was reproducible between visits (intraclass correlation 0.93). The absolute change in FEV(1) was independent of the pre-bronchodilator value but the percentage change correlated with pre-bronchodilator FEV(1) (r=-0.44; p<0.0001). Using ATS criteria, 52.1% of patients changed responder status between visits compared with 38.2% using ERS criteria. Smoking status, atopy, and withdrawing inhaled corticosteroids were unrelated to bronchodilator response, as was the rate of decline in FEV(1), decline in health status, and exacerbation rate.

CONCLUSION

In moderate to severe COPD bronchodilator responsiveness is a continuous variable. Classifying patients as "responders" and "non-responders" can be misleading and does not predict disease progression.

Describing three-dimensional cervical spine movement in a diseased and a non-diseased group using multilevel modelling

Clinicians often request patients to perform movements of joints as an aid to assessment and diagnosis of many diseases. However, patients may perform abnormal secondary movements where their primary movement is limited. A new measuring system, the FASTRAK, has the potential to measure movement in three dimensions, and to measure movements of the body away from the primary movement. This paper explores the use of multilevel modelling to describe the patterns of movement where subjects are measured on several occasions for both a non-diseased group and for a group of subjects suffering from ankylosing spondylitis. Three-level multilevel models are described with level 3 being the subjects, level 2 being the measurement occasions (up to three) and level 1 being the measurements (three) on each occasion. The models highlight which are the most important secondary movements during the primary movement and show clinically interpretable patterns of movement that can highlight differences between diseased and non-diseased groups.

Time course of recovery of health status following an infective exacerbation of chronic bronchitis

BACKGROUND

The magnitude and time course of effect of an acute exacerbation of chronic bronchitis (AECB) on health status are not known. Data from the GLOBE study, a randomised double blind trial of antibiotic therapy, were used to investigate these effects.

METHODS

438 patients with AECB received either gemifloxacin 320 mg once daily for 5 days (214 patients) or clarithromycin 500 mg twice daily for 7 days (224 patients) and were followed up for 26 weeks. St George's Respiratory Questionnaire (SGRQ) scores were obtained at baseline and after 4, 12, and 26 weeks.

RESULTS

At presentation during an exacerbation SGRQ scores were worse (Total score difference 5.4 units, 95% CI 1.9 to 8.8, p=0.002) in patients who had a subsequent exacerbation during follow up. The greatest improvement in SGRQ score occurred within the first 4 weeks (mean 8.9 units, 95% CI 6.5 to 11.5, p<0.0001). Subsequently, scores improved more rapidly in patients with no further exacerbations. At 26 weeks the difference between the two groups was 9.6 units (95% CI 5.7 to 13.4, p<0.0001). In patients with no further exacerbations the SGRQ score improved between 4 and 12 weeks by a further 4.1 units (95% CI 2.2 to 5.9, p<0.0001).

CONCLUSIONS

A single infective AECB has a sustained effect on health status. The recovery period is long even in patients who have no further exacerbations. A second episode within 6 months limits recovery markedly. Treatments that reduce exacerbation frequency could have a significant impact on health status.

Methodological issues in evaluating measures of health as outcomes for COPD

The selection of an appropriate outcome measure depends on the aspect of the disease being addressed and the purpose of the study being conducted. The most fundamental property of any outcome is its ability to measure the biological variable under question. Other properties such as discriminative and evaluative abilities are also important. Specific outcomes measure a single biological variable, such as forced expiratory volume in one second or depression. The specificity of such measures is attractive but requires precise definition of what is being measured and why. Other, summative, outcomes are used to quantify the overall effect of a number of different biological processes. The simplest summative measures are global questions such as "How would you rate your health overall?" Others are complex with many items. If designed and used correctly, these questionnaires can provide an estimate of the overall impact of disease or response to therapy and an index of whether that response was clinically worthwhile. Standardisation of measurements is important to permit comparisons between patients and studies, which makes the measurement of an individual's "quality of life" difficult. The term "health-status measurement" may be better when referring to the use of standardised questionnaires. Utility-based measures help address concerns regarding clinical versus statistical improvement and place outcomes for chronic obstructive pulmonary disease treatment trials in the context of all healthcare treatments.

Breathing retraining for asthma

Breathing retraining is used increasingly throughout the world by many patients with asthma in addition to their usual medical care. We undertook a systematic review of the literature in order to determine the effectiveness of breathing retraining in the management of asthma. Six randomised-controlled trials were identified that involved breathing retraining in asthma. Due to the variation in reported trial outcomes, limited reporting of study data and small number of included trials it was not possible to draw any firm conclusions as to its effectiveness. However, outcomes that were reported from individual trials do show that breathing retraining may have a role in the treatment and management of asthma. Further large-scale trials using breathing retraining techniques in asthma are required to address this important issue.

Serum from patients anesthetized with opiates less effective in the support of chondrocyte growth in vitro

Risk of viral and/or prion disease transmission associated with the use of fetal bovine serum in clinical cell culture has led to the increasing use of autologous human serum in tissue engineering. A relatively large volume of blood is needed and so, to decrease patient discomfort, we have investigated the feasibility of taking blood when the patient is anesthetized. Two serum samples were prepared from each of 22 patients: (1). from the awake patient (PRE) and (2). from the patient 5 min after induction of general anesthesia (PER). The sera were compared for their ability to support the in vitro proliferation of primary human chondrocytes, determined by cell counting. The effects of anesthetic agents on the PER/PRE cell number ratio were established by analysis of variance and stepwise multilinear regression analysis. The PER sample supported higher growth in 2 of 22 patients, equivalent growth in another 11, and significantly lower growth in the remaining 8. Only the opiate analgesics (fentanyl [Sublimaze], alfentanyl [Rapifen], and diamorphine) had a significant and inhibitory effect on chondrocyte proliferation. It is suggested that opiate analgesics be avoided when blood is taken to support the in vitro growth of human cells.

Disease severity and the effect of fluticasone propionate on chronic obstructive pulmonary disease exacerbations

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with worse health and increased healthcare utilisation. The Inhaled Steroids in Obstructive Lung Disease in Europe (ISOLDE) study in COPD showed a 26% reduction in the yearly rate of exacerbations in patients treated with fluticasone propionate (FP) compared to placebo, but did not indicate which patients showed greatest benefit. In this study the patients were stratified into mild and moderate-to-severe COPD using the American Thoracic Society criterion of forced expiratory volume in one second (FEV1) 50% predicted, and the total number of exacerbations and those requiring treatment with oral corticosteroids were examined. There were 391 (195 FP) patients with mild COPD and 359 (180 FP) patients with moderate-to-severe disease. The exacerbation rate was highly skewed in mild disease, but more normally distributed in moderate-to-severe disease. FP reduced the overall exacerbation rate in moderate-to-severe disease (FP median rate 1.47 yr(-1), placebo 1.75 yr(-1)), but not in mild disease (FP 0.67 yr(-1), placebo 0.92 yr(-1)). FP use was associated with fewer patients with > or = 1 exacerbation x yr(-1) being treated with oral corticosteroids (mild: FP 8%, placebo 16%; moderate-to-severe: FP 17%, placebo 30%). Effects of fluticasone propionate on exacerbations were seen predominantly in patients with a postbronchodilator forced expiratory volume in one second <50% predicted. These data support recommendations in the Global Initiative for Chronic Obstructive Disease treatment guidelines that inhaled corticosteroids should be considered in patients with moderate-to-severe chronic obstructive pulmonary disease who experience recurrent exacerbations.

An introduction to systematic reviews in respiratory medicine

Reviews are an essential component of modern medicine. The volume of literature is large, even about a single treatment for pulmonary disease. The task of retrieving all the relevant papers, then assessing the evidence to reach a valid conclusion is very time consuming. At every stage there is the risk of sampling error (failure to get all the evidence) and bias (a systematic distortion of the results due to a weakness in the methodology). There are essentially two types of review: narrative reviews that follow no rules, exposing them to sampling error and bias; and systematic reviews that attempt to minimise these effects by following an explicit structure for retrieving all of the evidence and attempting an objective synthesis of the results from the different trials. A good review can serve a number of purposes including: assembling all the relevant evidence in one place, providing a valid estimate of the overall effect of treatment, producing guidance for clinical practice and generating hypotheses for further trials about patients or settings in which the treatment effect may be less or more effective.

Cost-effectiveness of salmeterol in patients with chronic obstructive pulmonary disease: an economic evaluation

Chronic obstructive pulmonary disease (COPD) is associated with a large economic and social burden. Few economic studies have examined the benefits of inhaled therapy for patients with COPD. This 16-week study examined the cost-effectiveness of salmeterol in this patient group. Patients with a history of COPD were randomised to treatment with salmetrol 50 mcg (229 patients) or placebo (227 patients) twice daily administered by metered-dose inhaler in addition to normal therapy. Forced expiratory volume (FEV1) was measured and patients recorded the impact of their symptoms in a daily diary. Health status was assessed using the St Georges Respiratory Questionnaire. A significantly higher proportion of salmeterol-treated patients had an increase of >15% in FEV1. Salmeterol patients had a higher mean proportion of symptom-free days and nights than those in the placebo group. More salmeterol patients had a clinically significant improvement in health status. Total healthcare costs were increased in the salmeterol group, but hospital and GP visit costs and concurrent COPD medication costs were lower. The reduction in hospital costs was sufficient to offset a substantial portion of the acquisition cost of salmeterol. Addition of salmeterol to COPD patients' current therapy improved lung function, health status at the expense of a modest increase in costs compared with usual therapy.

Relationship between psychological well-being and lung health status in patients with bronchiectasis

Patients with bronchiectasis often complain of abnormal tiredness, difficulty in concentrating or low spirits. This study was carried out to examine levels of anxiety and depression in bronchiectasis and their relationship with other measures of lung health. One hundred and eleven patients with bronchiectasis determined by high-resolution computed tomography (CT) scan were studied using a range of physiological and psychological outcome measures. Patients completed anxiety and depression, health status (quality of life), fatigue and dypnoea questionnaires. Lung function was measured and exercise capacity was assessed using a shuttle walk test. Anxiety and depression scores formed a continuum. Moderate-severe anxiety was more frequent than equivalent levels of depression (17 vs 9% of patients). Anxiety and depression scores were associated with perceived health status (r=0.33 and 0.55). Neither anxiety nor depression was associated with the extent of bronchiectasis on CT scan. Depression was correlated with breathlessness and exercise performance (r=0.33 and 0.40), but anxiety was not. The correlation between depression and exercise performance was not simply due to the influence of somatic items in the depression questionnaire. We conclude that anxiety and depression are quite common in bronchiectasis in that 34% of patients had elevated scores for anxiety depression or both. The non-somatic components of depression were linked to dyspnoea and exercise performance, but anxiety was only related to perceived health. Therefore, treatment aimed at reducing symptoms and improving exercise capacity will not reduce levels of anxiety which need alternative therapy.

Applying evidence and theory to guide clinical decision making--implications for asthma management

Evidence-based medicine has been described as the "conscientious, explicit and judicious use of current best evidence in making decisions about the healthcare of individual patients". Many sources of information may be used by doctors when making decisions about initiating asthma therapy. These include: personal experience, postgraduate education, continuous professional development and publications in peer-reviewed journals. However, despite these sources of information, available data suggest that it is often difficult to practice evidence-based medicine, particularly in general practice. In the future, physicians will be provided with better evidence of the relative efficacy of treatment to aid changes in clinical practice. This will be provided, in part, by large well-conducted clinical trials, systematic reviews and meta-analyses. Linked with these, will be other methods of presenting data, for example, the number of patients needed to treat (NNT) to prevent one clinically significant event (for example, an asthma exacerbation). Despite these advances, incorporation of evidence-based practice into routine asthma care will be a slow and complex process. However, this process can be facilitated by physician education and participation in intervention programmes. In addition, it is important that clinicians are trained in how to convey the best possible evidence to their asthma patients.

Interleukin 1 genotypes in multiple sclerosis and relationship to disease severity

We studied the association between clinical outcome in MS and allelic variants single nucleotide polymorphisms (SNPs) of interleukin-1alpha (IL-1alpha), IL-1beta and a variable number tandem repeat (VNTR) in IL-1 receptor antagonist (IL-1RN). A total of 377 patients with MS were studied. Significant associations between IL-1 genotypes and clinical outcome were found using logistic regression after correction for gender, onset age and disease duration. The same trends were subsequently demonstrated in a second independent group of 67 primary progressive patients. Our results suggest that genetically determined immunomodulation mediated by IL-1 influences long-term prognosis in multiple sclerosis (MS).

Computer modelling of the chemical speciation of caesium, uranium(VI) and neptunium(V) in human duodenal fluids under fasting conditions

A model simulating the human duodenal contents under physiologically realistic, fasting conditions was developed using the joint expert speciation system (JESS) computer program and database and used to investigate the chemical speciation of caesium, uranium(VI) and neptunium(V). Over the pH range 5.0-9.0, and the concentration range 5 x 10(-15) x 10(-5) mol dm(-3), caesium was predicted to occur predominantly as the absorbable free monovalent cation Cs+ (approximately 95%) with species such as CsHPO4- and CsCl representing the remainder. The presence or absence of sulphate at 2.1 x 10(-3) mol dm(-3) did not influence the predicted speciation. Uranium was predicted to be present entirely as a soluble, highly charged species, both in the absence and in the presence of sulphate. Between pH 5.0 and approximately 6.5 the UO2H2(PO4)2(2-) predominated, above this pH carbonate species, either UO2(CO3)4(6-) or, possibly, UO2(CO3)5(8-). At pH 8.0, and in the presence of sulphate, neptunium(V) was predicted to exist solely as the tetrasulphate species, whilst in the absence of sulphate, an array of negatively charged soluble carbonate species predominated. Studies over the pH range 5.0-9.0 predicted the formation of a spectrum of negatively charged carbonate and phosphate species, approximately 40% of the total neptunium was predicted to be present as the electrically net-neutral species NpO2HCO3 at pH6.0, approximately 20% at pH 7.0, approximately 10% at pH 7.5 and approximately 1% at pH 8.0. The observed speciation patterns of uranium and neptunium did not change over the concentration range 5 x 10(-15) - 5 x 10(-5) mol dm(-3) and no solid species were predicted to occur under the conditions simulated. Whether the predicted electrically net-neutral neptunium species or the uranium pentacarbonate species do actually occur under true physiological conditions remains to be established. The observed speciation patterns for caesium and uranium are consistent with the observed absorption of these elements by humans; however, the observations for neptunium appear to be equivocal.

The 'Severe Hypertensive Illness in Pregnancy' (SHIP) audit: promoting quality care using a high risk monitoring chart and eclampsia treatment pack

We set out to measure the standards of care in a regional cohort of women with severe hypertensive illness of pregnancy and to subsequently improve the quality of care using a series of interventions. This was a multi centre cyclical criterion audit involving 21 maternity units in the West Midlands Region. Prospective data collection involved named co-ordinators in each unit using customised proformas. Intervention comprised feedback of baseline results to each hospital, a monitoring chart and eclampsia treatment pack. The first audit period (n = 183) was for a 4-month period between 1/9/96 and 31/12/96 and the second audit period (n = 111) was during the same 4-month period 1 year later. Although compliance with the audit standards set increased in all but one standard, there is clearly a need to make further improvements in the quality of care administered.

Physical therapy in spasticity

Physiotherapists are part of the rehabilitation team involved in the management of adult spasticity. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. Identifying the physiological changes brought about by physical therapy or physiotherapy, is difficult. As with many interventions in rehabilitation, this area is poorly studied and, until recently, there was little or no evidence for its effectiveness. The aim of this presentation is to identify key components of a physiotherapy approach and outline specific techniques. The key components considered are: education of the patient and their carers; the 'intervention cycle' - involving accurate assessment, careful measurement, intervention and evaluation; accurate goal setting and a staged stepwise approach over prolonged periods. The specific techniques used include treatments targeted at: muscle length changes, muscle strengthening and functional performance. Broadly these techniques can be divided into biomechanical, cognitive and neurophysiological, each being interdependent on the others. Physiotherapy combined with the other available treatments should meet the challenge arising from adult spasticity.

Prescribing patterns in premenstrual syndrome

BACKGROUND: Over 300 therapies have been proposed for premenstrual syndrome. To date there has been only one survey conducted in the UK of PMS treatments prescribed by GPs, a questionnaire-based study by the National Association of Premenstrual Syndrome in 1989. Since then, selective serotonin re-uptake inhibitors have been licensed for severe PMS/PMDD, and governmental recommendations to reduce the dosage of vitamin B6 (the first choice over-the-counter treatment for many women with PMS) have been made. This study investigates the annual rates of diagnoses and prescribing patterns for premenstrual syndrome (1993-1998) within a computerised general practitioner database. METHODS: Retrospective survey of prescribing data for premenstrual syndrome between 1993-1998 using the General Practice Research Database for the West Midlands Region which contains information on 282,600 female patients RESULTS: Overall the proportion of women with a prescription-linked diagnosis of premenstrual syndrome has halved over the five years. Progestogens including progesterone were the most commonly recorded treatment for premenstrual syndrome during the whole study period accounting for over 40% of all prescriptions. Selective serotonin-reuptake inhibitors accounted for only 2% of the prescriptions in 1993 but rose to over 16% by 1998, becoming the second most commonly recorded treatment. Vitamin B6 accounted for 22% of the prescriptions in 1993 but dropped markedly between 1997 and 1998 to 11%. CONCLUSIONS: This study shows a yearly decrease in the number of prescriptions linked to diagnoses for premenstrual syndrome. Progestogens including progesterone, is the most widely prescribed treatment for premenstrual syndrome despite the lack of evidence demonstrating their efficacy.

Can pre-operative computed tomography predict resectability of ovarian carcinoma at primary laparotomy?

OBJECTIVE

To assess the ability of computed tomography in predicting whether suspected ovarian cancer could be fully excised at primary laparotomy.

DESIGN

Retrospective analysis of patient notes and pre-operative computed tomography scans. Setting A UK NHS cancer centre.

POPULATION

Seventy-seven women who underwent laparotomy for an ovarian tumour and who had had a pre-operative computed tomography scan.

METHODS

Women who had a computed tomography scan before laparotomy for an ovarian tumour were identified. Analysis was undertaken to determine the accuracy of computed tomography in predicting malignancy, stage and residual disease. The computed tomography parameters significantly associated with residual disease were determined by a chi2 analysis. These parameters, in addition to age and CA125, were used to generate a predictive model. This model was further refined by stepwise logistic regression and a clinical scoring index was generated.

MAIN OUTCOME MEASURES

To identify those computed tomography parameters significantly associated with residual disease and to use these with CA125 and age to generate a useful clinical scoring index to predict residual disease in suspected ovarian cancer.

RESULTS

Seventy-seven women underwent a laparotomy for an ovarian tumour and had a pre-operative computed tomography scan. Fifty-one of these women had malignant disease and twenty-five of these women had residual disease remaining. The sensitivity of computed tomography in predicting malignancy was 90% with a specificity of 85% and the overall accuracy of computed tomography for predicting stage of disease was 73% (37/51). The overall sensitivity of computed tomography in predicting residual disease was 88%, the specificity was 92% and the positive predictive value was 85%. The parameters on computed tomography that were significantly (P < 0.05) associated with residual disease were ascites, omental cake, mesenteric disease, paracolic gutter deposits, diaphragmatic deposits and pleural effusion. The predictive model generated was more accurate than computed tomography alone (sensitivity 88%, specificity 98%, positive predictive value 95%). Using stepwise logistic regression enabled the predictive model to be simplified to include mesenteric disease, omental cake, age and CA125 without any change in sensitivity or specificity and this model was used to generate a scoring index.

CONCLUSION

This study shows that prediction of resectability by computed tomography is excellent and is further improved by the generation of a predictive model, which can be used to generate a simple scoring index. This scoring system now needs to be tested prospectively to ensure that its performance remains as good in an independent sample population.

Corticosteroid therapy in pulmonary sarcoidosis: a systematic review

CONTEXT

Corticosteroids are used in pulmonary sarcoidosis to reduce symptoms and minimize long-term damage. Spontaneous recovery is a common feature. Both the decision to initiate therapy and the treatment response may be influenced by disease severity, so trials need to use a randomized controlled design.

OBJECTIVE

To assess the effect of oral and inhaled corticosteroids on chest radiograph results, symptoms, pulmonary function, and long-term outcome in pulmonary sarcoidosis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register were searched all years through December 2001. Bibliographies of review articles and retrieved articles were searched, and pharmaceutical companies and authors of identified trials were contacted for other studies. There was no language restriction.

STUDY SELECTION

Trials were randomized and included a control group. Participants were adults with histologic evidence of pulmonary sarcoidosis. Treatments included the use of oral and inhaled corticosteroids for at least 8 weeks. The search identified 150 studies; 9 met the inclusion criteria, but only 8 provided usable data.

DATA EXTRACTION

Two reviewers assessed trial quality using the Jadad score, which evaluates the quality of randomization, blinding, and reasons for withdrawal. Data were extracted and sent to primary authors for verification.

DATA SYNTHESIS

In patients with stage 2 and 3 disease, oral corticosteroids improved findings on the chest radiograph after 6 to 24 months (Peto odds ratio, 2.54; 95% confidence interval [CI], 1.69-3.81; P<.001). Forced vital capacity improved with oral corticosteroids (weighted mean difference [WMD], 4.2% predicted; 95% CI, 0.4%-7.9% predicted) and diffusing capacity also improved (WMD, 5.7% predicted; 95% CI, 1.0%-10.5% predicted). In 2 small studies of inhaled corticosteroids, there was no effect on chest radiograph and inconsistent effects on lung function in one and only a small improvement in symptoms in the other. There were no data following corticosteroid withdrawal to assess any disease-modifying effect.

CONCLUSIONS

Oral corticosteroids improved results on the chest radiograph following 6 to 24 months of treatment and produced a small improvement in vital capacity and diffusing capacity. Trials of inhaled corticosteroids were small and results too inconsistent to make firm conclusions concerning their efficacy. There are no data to suggest that corticosteroid therapy alters long-term disease progression.

Interpreting thresholds for a clinically significant change in health status in asthma and COPD

Health status (or Health-Related Quality of Life) measurement is an established method for assessing the overall efficacy of treatments for asthma and chronic obstructive pulmonary disease (COPD). Such measurements can indicate the potential clinical significance of a treatment's effect. This paper is concerned with methods of estimating the threshold of clinical significance for three widely used health status questionnaires for asthma and COPD: the Asthma Quality of Life Questionnaire, Chronic Respiratory Questionnaire and St George's Respiratory Questionnaire. It discusses the methodology used to obtain such estimates and shows that the estimates appear to be fairly reliable; ie. for a given questionnaire, similar estimates may be obtained in different studies. These empirically derived thresholds are all mean estimates with confidence intervals around them. The presence of these confidence intervals affects the way in which the thresholds may be used to draw inferences concerning the clinical relevance of clinical trial results. A new system of judging the magnitude of clinically significant results is proposed. Finally, an attempt is made to translate these thresholds into scenarios that illustrate what a clinically significant change with treatment may mean to an individual patient.