Endothelin receptor antagonists are an effective long term treatment option in pulmonary arterial hypertension associated with congenital heart disease with or without trisomy 21

INTRODUCTION

Traditionally, treatment options for patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) are limited. Bosentan has been shown to improve pulmonary haemodynamics and exercise tolerance short term but long term clinical studies are lacking.

AIM

To report long term efficacy and safety data with endothelin receptor antagonists (ERA) in patients with PAH associated CHD.

METHODS

Prospective, open label, uncontrolled, single centre study of 53 patients (33 females, 17 Trisomy 21, mean age 34 ± 12 years) prescribed ERA (48 bosentan, 5 sitaxentan) from 2003 to August 2009. Outcome measurements of oxygen saturation (SaO2), WHO functional class, 6-minute walk test distance (6MWD) and adverse events were analysed.

RESULTS

Mean duration of therapy was 15 ± 13 months in 53 patients with CHD. Four patients failed ERA, seven died (five progressive RHF) and one delisted from transplantation. No abnormal liver transaminases occurred on bosentan, with one case on sitaxentan. After 3, 6, 12, 18 and 24 months of treatment a significant improvement was seen in WHO functional class (mean 3.15 vs 2.8 vs 2.5 vs 2.5 vs 2.4 vs 2.4; p<0.01) and 6MWD (344 ± 18 vs 392 ± 17 vs 411 ± 17 vs 420 ± 17 vs 442 ± 18 vs 417 ± 23: p<0.0005, p<0.01) compared with baseline. The Trisomy 21 and PAH-CHD showed a significant improvement in 6MWD at 6 and 12 months (263 ± 24 vs 348 ± 29 vs 360 ± 32, p<0.01, p<0.05) respectively. No changes in SaO2, BNP, RV or LV function were demonstrated during follow-up.

CONCLUSION

This large single centre study demonstrates that endothelin receptor antagonism is an effective and safe treatment in PAH associated CHD with or without Trisomy 21. The improvements in exercise tolerance are similar to reported benefits in other forms of PAH.

Endothelin receptor antagonists are an effective long term treatment option in pulmonary arterial hypertension associated with congenital heart disease with or without trisomy 21

INTRODUCTION

Traditionally, treatment options for patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) are limited. Bosentan has been shown to improve pulmonary haemodynamics and exercise tolerance short term but long term clinical studies are lacking.

AIM

To report long term efficacy and safety data with endothelin receptor antagonists (ERA) in patients with PAH associated CHD.

METHODS

Prospective, open label, uncontrolled, single centre study of 53 patients (33 females, 17 Trisomy 21, mean age 34 ± 12 years) prescribed ERA (48 bosentan, 5 sitaxentan) from 2003 to August 2009. Outcome measurements of oxygen saturation (SaO2), WHO functional class, 6-minute walk test distance (6MWD) and adverse events were analysed.

RESULTS

Mean duration of therapy was 15 ± 13 months in 53 patients with CHD. Four patients failed ERA, seven died (five progressive RHF) and one delisted from transplantation. No abnormal liver transaminases occurred on bosentan, with one case on sitaxentan. After 3, 6, 12, 18 and 24 months of treatment a significant improvement was seen in WHO functional class (mean 3.15 vs 2.8 vs 2.5 vs 2.5 vs 2.4 vs 2.4; p<0.01) and 6MWD (344 ± 18 vs 392 ± 17 vs 411 ± 17 vs 420 ± 17 vs 442 ± 18 vs 417 ± 23: p<0.0005, p<0.01) compared with baseline. The Trisomy 21 and PAH-CHD showed a significant improvement in 6MWD at 6 and 12 months (263 ± 24 vs 348 ± 29 vs 360 ± 32, p<0.01, p<0.05) respectively. No changes in SaO2, BNP, RV or LV function were demonstrated during follow-up.

CONCLUSION

This large single centre study demonstrates that endothelin receptor antagonism is an effective and safe treatment in PAH associated CHD with or without Trisomy 21. The improvements in exercise tolerance are similar to reported benefits in other forms of PAH.

Aerobic exercise interventions for adults living with HIV/AIDS

BACKGROUND

Access to combination antiretroviral therapy has turned HIV into a chronic and manageable disease for many. This increased chronicity has been mirrored by increased prevalence of health-related challenges experienced by people living with HIV (Rusch 2004). Exercise is a key strategy for people living with HIV and by rehabilitation professionals to address these disablements; however, knowledge about the effects of exercise among adults living with HIV still is emerging.

OBJECTIVES

To examine the safety and effectiveness of aerobic exercise interventions on immunologic and virologic, cardiopulmonary, psychologic outcomes and strength, weight, and body composition in adults living with HIV.

SEARCH STRATEGY

Searches of MEDLINE, EMBASE, SCIENCE CITATION INDEX, CINAHL, HEALTHSTAR, PsycINFO, SPORTDISCUS and Cochrane Review Group Databases were conducted between 1980 and June 2009. Searches of published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences were conducted, as well as a handsearch of reference lists and tables of contents of relevant journals and books.

SELECTION CRITERIA

We included studies of randomised controlled trials (RCTs) comparing aerobic exercise interventions with no aerobic exercise interventions or another exercise or treatment modality, performed at least three times per week for at least four weeks among adults (18 years of age or older) living with HIV.

DATA COLLECTION AND ANALYSIS

Data on study design, participants, interventions, outcomes, and methodological quality were abstracted from included studies by two reviewers. Meta-analyses, using RevMan 5 computer software, were performed on outcomes when possible.

MAIN RESULTS

A total of 14 studies met inclusion criteria for this review and 30 meta-analyses over several updates were performed. Main results indicated that performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 minutes at least three times per week for at least five weeks appears to be safe and may lead to significant improvements in selected outcomes of cardiopulmonary fitness (maximum oxygen consumption), body composition (leg muscle area, percent body fat), and psychological status (depression-dejection symptoms). These findings are limited to participants who continued to exercise and for whom there were adequate follow-up data.

AUTHORS' CONCLUSIONS

Aerobic exercise appears to be safe and may be beneficial for adults living with HIV. These findings are limited by the small sample sizes and large withdrawal rates described in the studies. Future research would benefit from participant follow-up and intention-to-treat analysis. Further research is required to determine the optimal parameters in which aerobic exercise may be most beneficial for adults living with HIV.

Tuberculosis testing in correctional officers: a national random survey of jails in the United States

SETTING

The correctional system in the United States is large and growing. The Centers for Disease Control and Prevention recommend baseline and annual testing of employees in correctional facilities for latent tuberculosis infection (LTBI).

OBJECTIVE

To describe the extent of and factors associated with LTBI testing practices for jail correctional officers.

DESIGN

A national survey of 1760 randomly selected jails was conducted. We used multivariable logistic regression models to examine factors associated with testing officers in a guideline-concordant manner and having a written policy.

RESULTS

A total of 1174 (67%) surveys were returned. Only 52% of jails had a written policy on LTBI testing of officers, and 51% screened officers at least annually (guideline concordance). Large jails (OR 2.41, 95%CI 1.67-3.49) and jails in states with a high tuberculosis incidence (OR 1.67, 95%CI 1.17-2.38) and in the Midwest (OR 1.58, 95%CI 1.07-2.33) were more likely to screen in a guideline-concordant manner.

CONCLUSION

Screening for LTBI among correctional officers in the United States was inconsistent. Strategies to improve LTBI testing among correctional officers are needed.

Expanding the lens of HIV services provision in Canada: results of a national survey of HIV health professionals

Those living with HIV may experience a range of disabilities, including body impairments, activity limitations, and social participation restrictions. The aim of this study was to examine HIV services provision in Canada by exploring practices, referrals, and service delivery challenges from the perspective of HIV health professionals (including nurses, physicians, social workers, pharmacists, psychologists, and dieticians), and to explore differences in referrals and perceived service delivery challenges by professional group, jurisdiction, community size, and practice in a Northern region. We conducted a nationwide mail survey with the population of selected HIV health professionals in Canada using the Dillman tailored design survey method. Of the 731 deliverable mailings, we received 462 (63%) responses, with 36% of eligible respondents completing the survey (n=214). The large majority (90%) of HIV professionals were located in metropolitan or urban communities and worked predominantly in hospital in-patient (42%), out-patient (50%), and HIV specialty clinic (46%) settings in one of the three provinces (Ontario, Quebec, and British Columbia) with the highest HIV prevalence. HIV health professionals referred primarily, and at relatively high levels, to AIDS service organizations (79%) and social workers (84%) to address participation restrictions and social issues; a lower percentage referred to rehabilitation professionals and other service providers to address impairments, activity limitations, or participation restrictions. Of respondents, 74% perceived barriers to care specific to HIV. Our results suggest that there is little difference in referral patterns by profession, jurisdiction, community size, or northern region of practice. There is a need for increased information and education of HIV health professionals that may refer to rehabilitation and other health services. In addition, new approaches are needed to coordinate multisectoral care and enhance the access and delivery of HIV rehabilitation health services to better meet the disablement needs of people living with HIV in Canada.

Rehabilitation in the context of HIV: an interprofessional multi-stakeholder process for curriculum development

With longer survival, individuals living with human immunodeficiency virus (HIV) infection are facing a multitude of health-related challenges due to HIV, its associated concurrent health conditions, and treatments. Despite the need for rehabilitation, few rehabilitation professionals work with people living with HIV, with many feeling they lack adequate knowledge and skills to assess and treat this population.

PURPOSE

We describe a national multi-stakeholder consultation used to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS.

METHODS

We conducted a series of focus groups and key informant interviews (either in person or by telephone) with people living with HIV, rehabilitation professionals, physicians, curriculum experts, and other HIV stakeholders. Participants were asked to describe their perceived learning needs of rehabilitation professionals and to identify relevant content and delivery methods for a future interprofessional HIV/AIDS curriculum.

RESULTS

Seven focus groups and 31 interviews with a total of 74 key informants were conducted, resulting in recommendations for content to include in HIV rehabilitation professional curricula and ways to deliver these curricula effectively.

CONCLUSIONS

A national multi-stakeholder environmental scan was a useful preliminary step to inform the development of an interprofessional curriculum for rehabilitation professionals on HIV/AIDS. Recommendations serve as scaffold from which to build content and delivery of future curricula.

Flexible high-conductivity carbon-nanotube interconnects made by rolling and printing

Applications of carbon nanotubes (CNTs) in flexible and complementary metal-oxide-semiconductor (CMOS)-based electronic and energy devices are impeded due to typically low CNT areal densities, growth temperatures that are incompatible with device substrates, and challenges in large-area alignment and interconnection. A scalable method for continuous fabrication and transfer printing of dense horizontally aligned CNT (HA-CNT) ribbon interconnects is presented. The process combines vertically aligned CNT (VA-CNT) growth by thermal chemical vapor deposition, a novel mechanical rolling process to transform the VA-CNTs to HA-CNTs, and adhesion-controlled transfer printing without needing a carrier film. The rolling force determines the HA-CNT packing fraction and the HA-CNTs are processed by conventional lithography. An electrical resistivity of 2 mOmega . cm is measured for ribbons having 800-nm thickness, while the resistivity of copper is 100 times lower, a value that exceeds most CNT assemblies made to date, and significant improvements can be made in CNT structural quality. This rolling and printing process could be scaled to full wafer areas and more complex architectures such as continuous CNT sheets and multidirectional patterns could be achieved by straightforward design of the CNT growth process and/or multiple rolling and printing sequences.

Comparison of codes assessing galactic cosmic radiation exposure of aircraft crew

The assessment of the exposure to cosmic radiation onboard aircraft is one of the preoccupations of bodies responsible for radiation protection. Cosmic particle flux is significantly higher onboard aircraft than at ground level and its intensity depends on the solar activity. The dose is usually estimated using codes validated by the experimental data. In this paper, a comparison of various codes is presented, some of them are used routinely, to assess the dose received by the aircraft crew caused by the galactic cosmic radiation. Results are provided for periods close to solar maximum and minimum and for selected flights covering major commercial routes in the world. The overall agreement between the codes, particularly for those routinely used for aircraft crew dosimetry, was better than +/-20 % from the median in all but two cases. The agreement within the codes is considered to be fully satisfactory for radiation protection purposes.

IASON-FREE: theory and experimental comparisons

A sophisticated flight code named FREE (acronym for Flight Route Effective Dose Estimation) was built for professional commercial usage. During its creation special precautions have been taken to take correctly into account all existing dependencies and details, so that the best possible result is achieved. Some of these factors are presented in detail and their effect on doses or dose rates is estimated. Detailed comparisons to more recent measurements for both quiescent as well as disturbed conditions are presented. The agreement at undisturbed conditions turns out to be excellent and also the comparisons to measured transient effects are very satisfactory.

Case report: group B streptococcal bacteremia and sacroiliitis after mid-trimester dilation and evacuation

Group B streptococcal bacteremia with septic arthritis is a rare complication of second trimester dilation and evacuation, and may cause substantial post-operative morbidity. A 37-year-old gravida 4 para 1-0-2-1 presented with fever and right hip pain on post-operative day 11 from a second trimester dilation and evacuation for fetal trisomy 21. She was initially found to have septic arthritis involving the right sacroiliac joint and group B streptococcal bacteremia. Transesophageal echocardiogram showed a tricuspid valve, vegetation consistent with endocarditis. After prolonged parenteral antibiotic therapy, she developed septic pulmonary emboli that were successfully treated with anticoagulation therapy. Group B streptococcal infection is a potentially serious post-abortion complication that can cause sacroiliitis, endocarditis and septic pulmonary emboli.

Visual and fine-motor outcomes in adolescent survivors of high-risk congenital diaphragmatic hernia who did not receive extracorporeal membrane oxygenation

OBJECTIVE

Although survivors of congenital diaphragmatic hernia (CDH) are at high risk for brain injury, little is known about their neurodevelopment. Studies exploring short-term outcomes in children who received extracorporeal membrane oxygenation (ECMO) therapy suggest an increased risk for abnormalities in tone and/or motor development. This study provides the first detailed examination of visual and fine-motor outcomes in adolescent survivors of high-risk CDH (manifesting within the first 24 h) who did not receive ECMO.

STUDY DESIGN

A total of 13 CDH survivors (mean age 12.9 years) and 11 typically developing controls, matched to the CDH sample in terms of age at test, intelligence quotient and socioeconomic status (SES), completed a battery of visual and motor tests.

RESULTS

CDH survivors performed normally on motor-free tests of visual-perceptual function and on tests requiring visual discrimination and scanning, but were impaired on tests requiring visual-motor integration and oral-motor programming.

CONCLUSION

Survivors of high-risk CDH who did not receive ECMO treatment are at risk for long-term problems with oral motor and visuomotor control.

Inspiratory Muscle Training Compared with Other Rehabilitation Interventions in Adults with Chronic Obstructive Pulmonary Disease: A Systematic Literature Review and Meta-Analysis

The purpose of this systematic review was to determine the effect of inspiratory muscle training (IMT) (alone or combined with exercise and/or pulmonary rehabilitation) compared to other rehabilitation interventions such as: exercise, education, other breathing techniques or exercise and/or pulmonary rehabilitation among adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature on IMT and COPD was conducted according to the Cochrane Collaboration protocol. Inclusion criteria for the review included randomized controlled trials, published in English, comparing IMT or combined IMT and exercise/pulmonary rehabilitation with other rehabilitation interventions such as general exercise, education, other breathing techniques or exercise/pulmonary rehabilitation among adults with COPD. 274 articles were retrieved, and 16 met the inclusion criteria. Seven meta-analyses were performed that compared targeted or threshold IMT to exercise (n = 3) or to education (n = 4). Results showed significant improvements in inspiratory muscle strength and endurance, and in the dyspnea scale on a quality of life measure, for participants in the IMT versus education group. In other instances where meta-analyses could not be performed, a qualitative review was performed. IMT results in improved inspiratory muscle strength and endurance compared to education. Further trials are required to investigate the effect of IMT (or combined IMT) compared to other rehabilitation inventions for outcomes such as dyspnea, exercise tolerance, and quality of life.

Effects of inspiratory muscle training in cystic fibrosis: a systematic review

OBJECTIVE

We performed a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis.

DATA SOURCES

MEDLINE, EMBASE and CINAHL electronic databases were searched up to January 2008.

REVIEW METHODS

We performed a systematic review using the methodology outlined in the Cochrane Collaboration protocol. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (> 13 years of age); (2) an IMT group was compared to a sham IMT, no intervention or other intervention group; (3) the study used a randomized controlled trial or cross-over design; and (4) it was published in English. Data were abstracted and methodological quality was assessed independently by two reviewers.

RESULTS

The search strategy yielded 36 articles, of which two met the inclusion criteria. Both studies used a targeted or threshold device for IMT. Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which showed no difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength. One study demonstrated improvement in inspiratory muscle endurance.

CONCLUSION

The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear. Future research should investigate the characteristics of the subgroup of people with cystic fibrosis that might benefit most from IMT.

Phase II trial of the farnesyltransferase inhibitor tipifarnib plus fulvestrant in hormone receptor-positive metastatic breast cancer: New York Cancer Consortium Trial P6205

BACKGROUND

Fulvestrant produces a clinical benefit rate (CBR) of approximately 45% in tamoxifen-resistant, hormone receptor (HR)-positive metastatic breast cancer (MBC) and 32% in aromatase inhibitor (AI)-resistant disease. The farnesyltransferase inhibitor tipifarnib inhibits Ras signaling and has preclinical and clinical activity in endocrine therapy-resistant disease. The objective of this study was to determine the efficacy and safety of tipifarnib-fulvestrant combination in HR-positive MBC.

PATIENTS AND METHODS

Postmenopausal women with no prior chemotherapy for metastatic disease received i.m. fulvestrant 250 mg on day 1 plus oral tipifarnib 300 mg twice daily on days 1-21 every 28 days. The primary end point was CBR.

RESULTS

The CBR was 51.6% [95% confidence interval (CI) 34.0% to 69.2%] in 31 eligible patients and 47.6% (95% CI 26.3% to 69.0%) in 21 patients with AI-resistant disease. A futility analysis indicated that it was unlikely to achieve the prespecified 70% CBR. Tipifarnib dose modification was required in 8 of 33 treated patients (24%).

CONCLUSIONS

The target CBR of 70% for the tipifarnib-fulvestrant combination in HR-positive MBC was set too high and was not achieved. The 48% CBR in AI-resistant disease compares favorably with the 32% CBR observed with fulvestrant alone in prior studies and merit further clinical and translational evaluation.

Harmonisation of multi-centre real-time reverse-transcribed PCR results of a candidate prognostic marker in breast cancer: an EU-FP6 supported study of members of the EORTC - PathoBiology Group

AIM

Assessment of intra- and inter-laboratory variation in multi-centre real-time reverse-transcribed PCR (qRT-PCR)-based mRNA quantification of a prognostic marker in breast cancer using external quality assurance (EQA).

METHODS

A questionnaire on the methodologies used and EQA calibrators were sent to 5 participating laboratories from 4 European countries, which measured mRNA levels of PITX2 splice variants and reference genes by qRT-PCR.

RESULTS

Differences in the methodology included PCR quantification methodology and equipment, RNA extraction and cDNA synthesis procedures. The intra-laboratory coefficient of variation (CV) ranged from 5 to 23%, and the inter-laboratory CV ranged from 17 to 30%. The inter-laboratory CV was reduced to 13% by using prediluted calibrators and by harmonising the data in the central QA laboratory. Additional normalisation using reference genes did not decrease the variation further.

CONCLUSIONS

Both externally provided calibrators and centralised harmonisation are required to reduce the intra-laboratory variation in multi-centre qRT-PCR results to an acceptable level.

The effects of eccentric versus concentric resistance training on muscle strength and mass in healthy adults: a systematic review with meta-analysis

The aim of this systematic review was to determine if eccentric exercise is superior to concentric exercise in stimulating gains in muscle strength and mass. Meta-analyses were performed for comparisons between eccentric and concentric training as means to improve muscle strength and mass. In order to determine the importance of different parameters of training, subgroup analyses of intensity of exercise, velocity of movement and mode of contraction were also performed. Twenty randomised controlled trials studies met the inclusion criteria. Meta-analyses showed that when eccentric exercise was performed at higher intensities compared with concentric training, total strength and eccentric strength increased more significantly. However, compared with concentric training, strength gains after eccentric training appeared more specific in terms of velocity and mode of contraction. Eccentric training performed at high intensities was shown to be more effective in promoting increases in muscle mass measured as muscle girth. In addition, eccentric training also showed a trend towards increased muscle cross-sectional area measured with magnetic resonance imaging or computerised tomography. Subgroup analyses suggest that the superiority of eccentric training to increase muscle strength and mass appears to be related to the higher loads developed during eccentric contractions. The specialised neural pattern of eccentric actions possibly explains the high specificity of strength gains after eccentric training. Further research is required to investigate the underlying mechanisms of this specificity and its functional significance in terms of transferability of strength gains to more complex human movements.

Is the Royal London Space Analysis reliable and does it influence orthodontic treatment decisions?

The purpose of this study was to investigate the reliability of the Royal London Space Analysis (RLSA) and to evaluate its influence on orthodontic treatment decisions. Thirty-one case records were collected to represent various levels of crowding and different types of malocclusions. Seventeen examiners assessed these records and completed a data sheet that recorded information on their treatment decision. One month later, the examiners attended a course on the RLSA and then used the analysis to rescore the 31 cases. The models were also scored by the expert who led the course and these were then considered the 'gold standard' scores. After a further month, the examiners reapplied the RLSA and formulated a treatment plan for each set of patient records. A paired Student's t-test and intraclass correlation coefficient (ICC) were used to assess the agreement in scoring RLSA, a paired sample t-test was used to compare the scores with the gold standard, and finally the reliability in treatment planning was determined using kappa (kappa) statistics. The scores for lower arch crowding showed the highest inter-examiner agreement with an ICC of 0.93 whereas the lowest level of agreement was for upper arch space requirement with an ICC of 0.77. Intra-examiner agreement was generally high, particularly for the assessment of lower arch crowding (ICC = 0.93) and lower arch space requirement (ICC = 0.88). There was excellent validity for all the examiners against the gold standard scores with a paired samples correlation ranging between 0.96 for lower arch crowding and 0.79 for upper arch space requirement. The intra-examiner reliability in treatment decision was only moderate, with an average kappa value of 0.52 (maximum 0.82, minimum 0.24). Intra- and inter-examiner agreement for scoring the RLSA was acceptable. Nevertheless, the additional information obtained from the application of the RLSA did not have a substantial impact on the treatment decisions.

Factor Analysis: An Overview in the Field of Measurement

Purpose: This article provides an overview of factor analysis from the perspective of measurement in clinical research.

Summary of Key Points: Factor analysis is a statistical technique that identifies interrelationships among a set of items in an instrument and/or questionnaire and groups them into homogeneous domains. Exploratory factor analysis can be used to reduce the number of items in a questionnaire and identify its underlying domains. Confirmatory factor analysis can be used to test a hypothesis about the domain structure of a questionnaire. Principal component analysis and common factor analysis are the most common techniques and differ based on the amount of variability that is analyzed among items. Steps of the factor analytical process include assessing correlation matrices, factor extraction, choosing the number of factors to retain, assessing the factor loading matrix, factor rotation and factor interpretation. Because no standardized method exists, factor analysis involves decision-making at each step.

Conclusions: The different techniques and methods of factor analysis each have unique strengths and limitations. Clinicians and researchers reviewing articles on factor analysis should ensure that authors state a priori their purpose, conceptual approach, preferred technique and methods that will guide their decision-making.

Efficacy and safety of etoricoxib 30 mg and celecoxib 200 mg in the treatment of osteoarthritis in two identically designed, randomized, placebo-controlled, non-inferiority studies

OBJECTIVE

To compare the efficacy of etoricoxib 30 mg with the generally maximum recommended dose of celecoxib, 200 mg, in the treatment of osteoarthritis (OA) in two identically designed studies.

METHODS

Two multi-centre, 26-week, double-blind, placebo-controlled, non-inferiority studies were conducted, enrolling patients who were prior non-steroidal anti-inflammatory drug (NSAID) or acetaminophen users. There were 599 patients in study 1 and 608 patients in study 2 randomized 4:4:1:1 to etoricoxib 30 mg qd, celecoxib 200 mg qd or one of two placebo groups for 12 weeks. After 12 weeks, placebo patients were evenly distributed to etoricoxib or celecoxib based on their initial enrollment randomization schedule. The primary hypothesis was that etoricoxib 30 mg would be at least as effective as celecoxib 200 mg for the time-weighted average change from baseline over 12 weeks for Western Ontario and McMaster (WOMAC) Pain Subscale, WOMAC Physical Function Subscale and Patient Global Assessment of Disease Status. Active treatments were also assessed over the full 26 weeks. Adverse experiences were collected for safety assessment.

RESULTS

In both studies, etoricoxib was non-inferior to celecoxib for all three efficacy outcomes over 12 and 26 weeks; both were superior to placebo (P < 0.001) for all three outcomes in each study over 12 weeks. The safety and tolerability of etoricoxib 30 mg qd and celecoxib 200 mg qd were similar over 12 and 26 weeks.

CONCLUSIONS

Etoricoxib 30 mg qd was at least as effective as celecoxib 200 mg qd and had similar safety in the treatment of knee and hip OA; both were superior to placebo. ClinicalTrials.gov Identifiers: NCT00092768; NCT00092791.

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review

The purpose of this study was to conduct a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature was conducted according the Cochrane Collaboration protocol using Medline and CINAHL. Nineteen of 274 extracted articles met the inclusion criteria and addressed comparisons of interest which included: IMT versus sham; IMT versus no intervention; low- versus high-intensity IMT; and two different modes of IMT. Thirteen meta-analyses were reported. Results indicate that targeted resistive or threshold IMT was associated with significant improvements in some outcomes of inspiratory muscle strength (PI(max) (cm H2O)) and endurance (Inspiratory Threshold Loading (kPa)), exercise capacity (Borg Scale for Respiratory Effort (modified Borg scale), Work Rate maximum (Watts)), and dyspnea (Transition Dyspnea Index), whereas IMT without a target or not using threshold training did not show improvement in these variables. There was no conclusive evidence regarding quality of life measures. IMT is effective for adults with COPD when using threshold or targeted devices that control or provide a target for training intensity.

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review

The purpose of this study was to conduct a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature was conducted according the Cochrane Collaboration protocol using Medline and CINAHL. Nineteen of 274 extracted articles met the inclusion criteria and addressed comparisons of interest which included: IMT versus sham; IMT versus no intervention; low- versus high-intensity IMT; and two different modes of IMT. Thirteen meta-analyses were reported. Results indicate that targeted resistive or threshold IMT was associated with significant improvements in some outcomes of inspiratory muscle strength (PI(max) (cm H2O)) and endurance (Inspiratory Threshold Loading (kPa)), exercise capacity (Borg Scale for Respiratory Effort (modified Borg scale), Work Rate maximum (Watts)), and dyspnea (Transition Dyspnea Index), whereas IMT without a target or not using threshold training did not show improvement in these variables. There was no conclusive evidence regarding quality of life measures. IMT is effective for adults with COPD when using threshold or targeted devices that control or provide a target for training intensity.

Aerobic Exercise Interventions for People Living with HIV/AIDS: Implications for Practice, Education, and Research

Purpose: The purpose of this article is to present the results of a systematic review that investigated the effects of aerobic exercise interventions in people living with HIV/AIDS and to discuss the implications for physical therapy practice, education, and research.

Summary of Key Points: A systematic review was conducted based on the Cochrane Collaboration protocol. Eleven randomized trials of HIVpositive adults who performed aerobic exercise three times per week for at least four weeks were identified. Thirteen meta-analyses were performed. The main results indicated that aerobic exercise was associated with significant improvements in some outcomes of cardiopulmonary status (maximum oxygen consumption) and psychological status (depression-dejection symptoms).

Conclusions: Performing continuous or interval aerobic exercise or a combination of continuous aerobic exercise and progressive resistive exercise for at least 24 minutes three times per week for at least five weeks appears to be safe and may be beneficial for adults living with HIV. These findings should be interpreted cautiously owing to small sample sizes and high withdrawal rates within individual studies. The results of this review support the role of exercise and, more broadly, the role of rehabilitation practice, education, and research in the care and treatment of persons living with HIV.

Male sexual function improves after ileal pouch anal anastomosis

PURPOSE

Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis. However sexual functional disturbances after this procedure can be a concern for patients. Therefore the aim of this study was to determine the outcome of sexual-function related quality of life in male patients undergoing restorative proctocolectomy.

METHODS

One hundred and twenty-two male patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis between 1995 and 2000 were evaluated by the validated International Index of Erectile Function (IIEF) scoring instrument. This index scale examines sexual function in five categories. These are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The IIEF instrument was administered after surgery and then scores before and after RP/IPAA were evaluated and compared. The significance of age at the time of the surgery, type of surgery, type of anastomotic technique (mucosectomy vs stapled) and septic complications on sexual functional outcome were also investigated.

RESULTS

Mean age at the time of the surgery was 39.9 +/- 11.5 years. The mean follow-up period (time between pouch surgery and IIEF completed) was 3.6 +/- 1.8 years. There was statistically significant improvement in 4 of 5 categories of sexual function (erectile function, sexual desire, intercourse satisfaction, and overall satisfaction) where patients had improved scores after surgery compared to prior to surgery. The mean erectile function score increased pre to post surgery by 2.12 points (P = 0.02), which indicates better sexual results. Anastomotic technique and septic complication did not influence the results, however, older age had a negative impact on results.

CONCLUSIONS

Despite some adverse sexual functions, male patients who undergo RP/IPAA for the surgical management of their colitis may preserve or improve their overall sexual functional outcome.

Is inspiratory muscle training effective for individuals with cervical spinal cord injury? A qualitative systematic review

OBJECTIVE

To perform a systematic review to determine the effect of inspiratory muscle training (IMT) in adults with cervical spinal cord injury (CSCI).

DESIGN

A systematic search of the literature on IMT and CSCI according to the Cochrane Collaboration protocol was performed. We searched electronic databases up to August 2003 including MEDLINE and CINAHL, searched reference lists from pertinent articles and books, made personal contact with authors, and hand searched targeted journals to identify potential studies for inclusion.

STUDY SELECTION

Inclusion criteria for the review included randomized controlled trials published in English comparing IMT with another comparison group among adults with CSCI.

DATA EXTRACTION

Two reviewers abstracted relevant data from included studies. Methodological quality of the studies was assessed using criteria developed by Jadad et al. We also assessed whether the comparison groups were similar at baseline and whether an intention-to-treat analysis was performed.

RESULTS

Forty articles were retrieved and three met the inclusion criteria. All studies used inspiratory resistance muscle trainers for at least 15 min, twice daily, five to seven days per week for six to eight weeks. Meta-analysis could not be performed due to differences in study design and outcomes. Only one study reported a positive effect of IMTcompared to control for measures of dyspnoea and pulmonary function.

CONCLUSION

Literature on the effect of IMT among adults with CSCI is scarce and an overall effect could not be confirmed.

Rate of progression of cognitive decline in Alzheimer's disease: effect of butyrylcholinesterase K gene variation

OBJECTIVE

To determine whether individuals with Alzheimer's disease (AD) and the K variant allele of butyrylcholinesterase have a slower rate of cognitive decline than those without the K variant allele of butyrylcholinesterase.

METHOD

The cognitive status of 339 community based subjects with AD was assessed with the Mini Mental State Examination at baseline and yearly over a three year follow up period. The rates of cognitive decline of subjects with and without the K variant allele were compared.

RESULT

Presence of the K allele was associated with a slower average rate of cognitive decline in subjects with severe AD.

CONCLUSIONS

This finding is consistent with the suggestion that the K variant of butyrylcholinesterase has an important role in disease progression in AD, and this may have implications for treatment.

Aerobic exercise interventions for adults living with HIV/AIDS

BACKGROUND

The profile of HIV infection is constantly changing. Although once viewed as an illness progressing to death, among those with access to antiretroviral therapy, HIV can now present as a disease with an uncertain natural history, perhaps a chronic manageable disease for some. This increased chronicity of HIV infection has been mirrored by increased prevalence of disablement in the HIV-infected population (Rusch 2004). Thus, the needs of these individuals have increasingly included the management of impairments (problems with body function or structure as a significant deviation or loss, such as pain or weakness), activity limitations (difficulties an individual may have in executing activities, such as inability to walk) and participation restrictions (problems an individual may experiences in involvement in life situations, such as inability to work) (WHO 2001). Exercise is a key strategy employed by people living with HIV/AIDS and by rehabilitation professionals to address these issues. Exercise has been shown to improve strength, cardiovascular function and psychological status in seronegative populations (Bouchard 1993), but what are the effects of exercise for adults living with HIV? If the risks and benefits of exercise for people living with HIV are better understood, appropriate exercise may be undertaken by those living with HIV/AIDS and appropriate exercise prescription may be practiced by healthcare providers. If effective and safe, exercise may enhance the effectiveness of HIV management, thus improving the overall outcome for adults living with HIV.

OBJECTIVES

To examine the safety and effectiveness of aerobic exercise interventions on immunological/virological, cardiopulmonary and psychological parameters in adults living with HIV/AIDS.

SEARCH STRATEGY

To identify the appropriate studies, we conducted a search using MEDLINE, EMBASE, SCIENCE CITATION INDEX, AIDSLINE, CINAHL, HEALTHSTAR, PSYCHLIT, SOCIOFILE, SCI, SSCI, ERIC and DAI. We also reviewed both published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences such as the Intersciences Conference on Antimicrobial Agents and Chemotherapy (ICAAC), the Conference on Retroviruses and Opportunistic Infections (CROI), the Infectious Diseases Society of America Conference (IDSA) and the International AIDS Conference (IAC). Reference lists from pertinent articles and books were reviewed and personal contacts with authors were used, as well as Collaborative Review Group databases. Targeted journals were handsearched for relevant articles. There were no language restrictions. Searches for the original review covered the period from 1980 to July 1999. The first update of this review included an additional search of the literature, followed by identification of included studies that met the inclusion criteria from August 1999 to January 2001. For the second update, we conducted a search to identify additional studies published from February 2001 to August 2003.

SELECTION CRITERIA

Studies were included if they were randomized controlled trials (RCTs) comparing aerobic exercise interventions with no aerobic exercise interventions or another exercise or treatment modality, performed at least three times per week for at least four weeks among adults (18 years of age or older) living with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Data on study design, participants, interventions, outcomes and methodological quality were abstracted from studies that met the inclusion criteria onto specifically designed data collection forms by at least two reviewers. Meta-analysis was conducted using RevMan 4.2 computer software on outcomes whenever possible.

MAIN RESULTS

A total of 10 studies (six from the original search, two from the first updated search and two from this second updated search) met the inclusion criteria for this review. Main results indicated that performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 minutes, at least three times per week for four weeks appears to be safe and may lead to significant reductions in depressive symptoms and potentially clinically important improvements in cardiopulmonary fitness. These findings are limited to those participants who continued to exercise and for whom there was adequate follow-up data.

AUTHORS' CONCLUSIONS

Aerobic exercise appears to be safe and may be beneficial for adults living with HIV/AIDS. These findings are limited by the small sample sizes and large withdrawal rates of the included studies. Future research would benefit from an increased attention to participant follow-up and intention-to-treat analysis. Further research is required to determine the optimal parameters of aerobic exercise and stage of disease in which aerobic exercise may be most beneficial for adults living with HIV.

Rehabilitation in HIV/AIDS: development of an expanded conceptual framework

In industrialized countries where HIV infection is becoming a chronic, episodic condition, rehabilitation services have the potential to play an expanded role for people living with HIV/AIDS (PLHAs). However, little is known about rehabilitation in the context of HIV. This paper documents the development of an enhanced, multidisciplinary conceptual framework of rehabilitation in the context of HIV, using the perceptions of PLHAs and rehabilitation professionals. Rehabilitation, broadly defined, is a dynamic process that includes all prevention and/or treatment activities and/or services that address body impairments, activity limitations and participation restrictions for an individual. The framework was developed through broad consultation and interviews with thirteen key informants. Themes that emerged from analysis of interviews related to concepts of rehabilitation in the context of HIV, rehabilitation professionals' roles in the context of HIV, and barriers to access and delivery of rehabilitation services. While there was some variation, key informants generally viewed rehabilitation as a goal-oriented and client-centered process with the potential to impact a range of life domains. Themes were presented to members of a national advisory committee (including PLHAs and health care providers), who produced the foundation of the HIV rehabilitation framework. The framework uses the perspective of the person living with HIV/AIDS, and includes individual life domains that may be affected by HIV, drawing and expanding upon the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health.

Effectiveness of aerobic exercise in adults living with HIV/AIDS: systematic review

PURPOSE

The objective of this systematic review was to examine the effectiveness and safety of aerobic exercise interventions on immunological/virological, cardiopulmonary, and psychological outcomes in adults living with HIV/AIDS.

METHODS

Ten randomized trials of HIV-positive adults performing aerobic exercise three times per week for at least 4 wk were identified by searching 13 electronic databases, abstracts from conferences, reference lists, and personal contact with authors from 1980 to November 2002. At least two independent reviewers assessed articles for inclusion, extracted data, and assessed methodological quality. Random effects models were used for meta-analysis.

RESULTS

Main results indicated that aerobic exercise was associated with small nonsignificant changes in CD4 count (weighted mean difference: 14 cells x mm(-3), 95% CI: -26, 54), viral load (weighted mean difference: 0.40 log10 copies, 95% CI: -0.28, 1.07), and VO2(max) (weighted mean difference: 1.84 mL x kg(-1) x min(-1), 95% CI: -0.53, 4.20). Individual studies suggested that aerobic exercise may improve psychological well-being for adults living with HIV/AIDS. These findings are limited to those participants who continued to exercise and for whom there was adequate follow-up.

CONCLUSION

In conclusion, performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 min, at least three times per week for 4 wk may be beneficial and appears to be safe for adults living with HIV/AIDS. However, these findings should be interpreted cautiously due to small sample sizes and large dropout rates within the included studies. Future research would benefit from increased attention to participant follow-up and intention-to-treat analysis.

Cytomegalovirus transmission to extremely low-birthweight infants through breast milk

AIM

To determine the incidence, timing and clinical significance of acquired postnatal cytomegalovirus (CMV) in extremely low-birthweight (ELBW) infants.

METHODS

Prospective, longitudinal surveillance study. ELBW infants were recruited in the first week of life. Maternal blood was tested for CMV-specific IgG antibodies. Weekly urine samples were obtained from infants for CMV culture and rapid antigen testing. Data were collected regarding clinical course and breast milk intake.

RESULTS

Of 181 eligible infants, 119 infants, born to 101 mothers, were enrolled. Eighty of the 101 mothers had their serum checked for CMV status. Seventy percent of those tested were seropositive for CMV. Of the 65 infants born to seropositive mothers, 94% received breast milk during their hospital stay. Complete urine collection was obtained in 92 infants. CMV was cultured from the urine of only four infants, all of whom were born to seropositive mothers. Only one of these four infants was symptomatic. The range at which CMV was first detected was between 48 and 72 postnatal days of age.

CONCLUSIONS

Despite a very high CMV seropositivity rate in mothers of ELBW infants, and the previously reported high rate of CMV excretion into breast milk, the incidence of postnatal CMV transmission was extremely low in our study.

Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial

BACKGROUND

Chronic low back pain (LBP) is a growing health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat this condition, but have not demonstrated efficacy beyond 2 weeks, and no studies have shown that NSAIDs produce durable improvements in disability.

METHODS

To evaluate the efficacy and durability of effect of etoricoxib for chronic LBP, a randomized, double blind, placebo-controlled trial was conducted at 46 centres. Three hundred and twenty-five patients with chronic LBP requiring treatment with an NSAID or paracetamol were randomized 1:1:1 to etoricoxib 60 mg (n=109), 90 mg (n=106), or placebo (n=110), daily for 3 months. Pre-specified endpoints over 3 months included LBP intensity scale (visual analog scale 0-100 mm) time-weighted average change from baseline, the Roland-Morris Disability Questionnaire (RMDQ), the LBP bothersomeness scale, patient and investigator global assessments, and measures of quality of life.

RESULTS

Both etoricoxib groups experienced significant reductions in LBP intensity at 4 weeks versus placebo [-15.15 mm and -13.03 mm for 60 and 90 mg, respectively, probability (p)<0.001 for each], which was maintained over 3 months. Treatment resulted in significant improvement from baseline compared to placebo in RMDQ scores (etoricoxib 60 mg, -2.82 and 90 mg, -2.38, p<0.001 for each) over 12 weeks and most other efficacy endpoints. There were no significant differences between treatments in incidence of adverse events (AEs) or discontinuations due to AEs.

CONCLUSION

Etoricoxib provided significant relief of symptoms and disability associated with chronic LBP detected at 1 week, confirmed at 4 weeks, and maintained over 3 months. Reductions in chronic LBP severity corresponded to improvements in physical functioning and quality of life. All treatments were generally well tolerated.

Progressive resistive exercise interventions for adults living with HIV/AIDS

BACKGROUND

Due to medical advancements, many people living with HIV infection in developed countries are living longer (Palella 1998). HIV infection can now present as a chronic illness with an uncertain natural disease history. The changing course of HIV infection has lead to a potential increase in the prevalence and impact of disability in people living with HIV infection. Exercise is one key management strategy used by health care professionals to address impairments (problems with body function or structure as a significant deviation or loss such as pain or weakness), activity limitations (difficulties an individual may have in executing activities such as inability to walk) and participation restrictions (problems an individual may experience in life situations such as inability to work) in this population (World Health Organization 2001). Exercise may also be used to address unwanted changes in weight and body composition in people living with HIV infection. Aerobic exercise has been associated with improvements in strength, cardiovascular function, and psychological status in general populations (Bouchard 1993). Results of a systematic review suggested that aerobic exercise interventions appeared to be safe and may lead to improvements in cardiopulmonary fitness for adults living with HIV/AIDS (Nixon 2002). But what are the effects of progressive resistive exercise (PRE) for adults living with HIV infection?A better understanding of the effectiveness and safety of progressive resistive exercise will enable people living with HIV and their health care workers to practice effective and appropriate exercise prescription, thus contributing to improved overall outcomes for adults living with HIV infection.

OBJECTIVES

To examine the safety and effectiveness of progressive resistive exercise interventions on weight, body composition, strength, immunological/virological, cardiopulmonary and psychological parameters in adults living with HIV infection.

SEARCH STRATEGY

To identify studies to be included in this review, we searched the following databases: MEDLINE, EMBASE, CINAHL, COCHRANE, SCIENCE CITATION INDEX, PSYCHINFO, SOCIOLOGICAL ABSTRACTS, SSCI, ERIC, DAI and HEALTHSTAR. We also reviewed both published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences such as the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), the Conference on Retroviruses and Opportunistic Infections (CROI), the Infectious Diseases Society of America Conference (IDSA), and the International AIDS Conference (IAC). Reference lists from pertinent articles and books were reviewed, as well as Collaborative Review Group databases. Targeted journals were also hand searched for relevant articles. No language restriction was applied. The search strategy covered literature from 1980-August 2003.

SELECTION CRITERIA

We included studies that were randomized controlled trials (RCTs) comparing progressive resistive exercise interventions with no progressive resistive exercise or another exercise or treatment modality, performed at least three times per week, and lasting at least four weeks among adults (18 years of age or older) living with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Data collection forms were used by reviewers to abstract data pertaining to study design, participants, interventions, outcomes and methodological quality from the studies that met inclusion criteria. Whenever possible, meta-analyses were conducted on outcomes using RevMan 4.2.2 computer software.

MAIN RESULTS

Seven studies met the inclusion criteria for this systematic review. Meta-analysis was limited due to the following differences among the studies: types of exercise interventions, inclusion of co-intervention groups, level of exercise supervision, baseline body composition and testosterone levels of participants, types of outcomes assessed, and methodological quality of the individual studies.Main results indicated that performing progressive resistive exercise or a combination of progressive resistive exercise and aerobic exercise at least three times a week for at least four weeks appears to be safe and may lead to statistically and possibly clinically important increases in body weight and composition. Results also indicate exercise interventions may lead to clinically important improvements in cardiopulmonary fitness. Individual studies included in this review suggest that progressive resistive exercise interventions with or without aerobic exercise also contribute to improvements in strength and psychological status for adults living with HIV/AIDS. Individual studies indicate that progressive resistive exercise or a combination of progressive resistive and aerobic exercise appears to be safe for adults living with HIV/AIDS who are medically stable as a result of no change seen in immunological/virological status. These results are limited to those who continued to exercise and for whom there were adequate follow-up data.

REVIEWERS' CONCLUSIONS

Progressive resistive exercise or a combination of progressive resistive exercise and aerobic exercise appear to be safe and may be beneficial for adults living with HIV/AIDS. These findings are limited by the small number of studies that could be included in meta-analyses, small sample sizes and variable participant withdrawal rates among included studies. Future research would benefit from including participants at various stages of HIV infection, a greater proportion of female participants, and participants in a variety of age groups to increase the generalizability of results. Furthermore, future research would benefit from studies with larger sample sizes that conduct an "intention-to-treat" analysis (analysis of participants based on the groups to which they were originally allocated) to better understand outcomes of participants that withdraw from exercise interventions.

Unplanned hospital admission in children undergoing day-case surgery

BACKGROUND AND OBJECTIVE

Unplanned hospital admission is a measure of quality of care in the setting of day-case surgery. We set out to identify the incidence and causes of unplanned hospital admission in a paediatric day-case unit.

METHODS

A retrospective survey to determine the incidence and causes of unplanned hospital admissions in children undergoing day-case surgery. The survey covered the period from January 1996 until December 1999 inclusive in a university affiliated children's hospital. This hospital is the second largest paediatric referral centre in Ireland with total admissions across all specialities during the study period of 42 738.

RESULTS

During the study period 10 772 children underwent day-case surgery, of whom 242 (2.2%) experienced unplanned hospital admission. The reasons for admission were surgical 146 (54%), anaesthetic 44 (16%), social 38 (14%), medical 31 (11%) and unclassified 10 (4%). Pain, surgical complications and/or further management, admission for observation, extensive surgery and oozing were the commonest surgical reasons. Postoperative nausea and vomiting, anaesthetic-related complication and somnolence were the commonest anaesthetic causes responsible for admission. Surgery performed after 15:00 h was an important factor associated with admission for social reasons. Orthopaedic surgery accounted for the largest absolute number of unplanned admissions with 61 (25%), followed by urology with 46 (19%) and general surgery with 46 (19%). However, measured as percentage of caseload, urology had the highest proportion of unplanned hospital admissions.

CONCLUSION

This study demonstrated that the incidence and causes of unplanned hospital admission following day-case surgery in children are similar to those for adults.