An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Diffusion-weighted imaging and diagnosis of transient ischemic attack

Objective

Magnetic resonance (MR) diffusion-weighted imaging (DWI) is sensitive to small acute ischemic lesions and might help diagnose transient ischemic attack (TIA). Reclassification of patients with TIA and a DWI lesion as “stroke” is under consideration. We assessed DWI positivity in TIA and implications for reclassification as stroke.

Methods

We searched multiple sources, without language restriction, from January 1995 to July 2012. We used PRISMA guidelines, and included studies that provided data on patients presenting with suspected TIA who underwent MR DWI and reported the proportion with an acute DWI lesion. We performed univariate random effects meta-analysis to determine DWI positive rates and influencing factors.

Results

We included 47 papers and 9,078 patients (range = 18–1,693). Diagnosis was by a stroke specialist in 26 of 47 studies (55%); all studies excluded TIA mimics. The pooled proportion of TIA patients with an acute DWI lesion was 34.3% (95% confidence interval [CI] = 30.5–38.4, range = 9–67%; I² = 89.3%). Larger studies (n > 200) had lower DWI-positive rates (29%; 95% CI = 23.2–34.6) than smaller (n < 50) studies (40.1%; 95% CI = 33.5–46.6%; p = 0.035), but no other testable factors, including clinician speciality and time to scanning, reduced or explained the 7-fold DWI-positive variation.

Interpretation

The commonest DWI finding in patients with definite TIA is a negative scan. Available data do not explain why ⅔ of patients with definite specialist-confirmed TIA have negative DWI findings. Until these factors are better understood, reclassifying DWI-positive TIAs as strokes is likely to increase variance in estimates of global stroke and TIA burden of disease. ANN NEUROL 2014;75:67–76

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metres per minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.

Clinical and imaging services for TIA and minor stroke: results of two surveys of practice across the UK

OBJECTIVES

Transient ischaemic attack (TIA) is a medical emergency requiring rapid access to effective, organised, stroke prevention. There are about 90 000 TIAs per year in the UK. We assessed whether stroke-prevention services in the UK meet Government targets.

DESIGN

Cross-sectional survey.

SETTING

All UK clinical and imaging stroke-prevention services.

INTERVENTION

Electronic structured survey delivered over the web with automatic recording of responses into a database; reminders to non-respondents. The survey sought information on clinic frequency, staff, case-mix, details of brain and carotid artery imaging, medical and surgical treatments.

RESULTS

114 stroke clinical and 146 imaging surveys were completed (both response rates 45%). Stroke-prevention services were available in most (97%) centres but only 31% operated 7 days/week. Half of the clinic referrals were TIA mimics, most patients (75%) were prescribed secondary prevention prior to clinic referral, and nurses performed the medical assessment in 28% of centres. CT was the most common and fastest first-line investigation; MR, used in 51% of centres, mostly after CT, was delayed up to 2 weeks in 26%; 51% of centres omitted blood-sensitive (GRE/T2*) MR sequences. Carotid imaging was with ultrasound in 95% of centres and 59% performed endarterectomy within 1 week of deciding to operate.

CONCLUSIONS

Stroke-prevention services are widely available in the UK. Delays to MRI, its use in addition to CT while omitting key sequences to diagnose haemorrhage, limit the potential benefit of MRI in stroke prevention, but inflate costs. Assessing TIA mimics requires clinical neurology expertise yet nurses run 28% of clinics. Further improvements are still required for optimal stroke prevention.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, July 2010), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1982 to March 2010), SPORTDiscus (1949 to March 2010), and five additional databases (March 2010). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 32 trials, involving 1414 participants, which comprised cardiorespiratory (14 trials, 651 participants), resistance (seven trials, 246 participants), and mixed training interventions (11 trials, 517 participants). Five deaths were reported at the end of the intervention and nine at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. The majority of the estimates of effect were not significant. Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 8.66 metres per minute, 95% confidence interval (CI) 2.98 to 14.34), preferred gait speed (MD 4.68 metres per minute, 95% CI 1.40 to 7.96) and walking capacity (MD 47.13 metres per six minutes, 95% CI 19.39 to 74.88) at the end of the intervention. These training effects were retained at the end of follow-up. Mixed training, involving walking, increased preferred walking speed (MD 2.93 metres per minute, 95% CI 0.02 to 5.84) and walking capacity (MD 30.59 metres per six minutes, 95% CI 8.90 to 52.28) but effects were smaller and there was heterogeneity amongst the trial results. There were insufficient data to assess the effects of resistance training. The variability in the quality of included trials hampered the reliability and generalizability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence, and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training involving walking within post-stroke rehabilitation programmes to improve speed, tolerance, and independence during walking. Further well-designed trials are needed to determine the optimal exercise prescription and identify long-term benefits.

A systematic review of clinical trials of pharmacological interventions for acute ischaemic stroke (1955-2008) that were completed, but not published in full

BACKGROUND

We assessed the prevalence, and potential impact of, trials of pharmacological agents for acute stroke that were completed but not published in full. Failure to publish trial data is to be deprecated as it sets aside the altruism of participants' consent to be exposed to the risks of experimental interventions, potentially biases the assessment of the effects of therapies, and may lead to premature discontinuation of research into promising treatments.

METHODS

We searched the Cochrane Stroke Group's Specialised Register of Trials in June 2008 for completed trials of pharmacological interventions for acute ischaemic stroke, and searched MEDLINE and EMBASE (January 2007 - March 2009) for references to recent full publications. We assessed trial completion status from trial reports, online trials registers and correspondence with experts.

RESULTS

We identified 940 trials. Of these, 125 (19.6%, 95% confidence interval 16.5-22.6) were completed but not published in full by the point prevalence date. They included 16,058 participants (16 trials had over 300 participants each) and tested 89 different interventions. Twenty-two trials with a total of 4,251 participants reported the number of deaths. In these trials, 636/4251 (15.0%) died.

CONCLUSIONS

Our data suggest that, at the point prevalence date, a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field was not published in full. Over 16,000 patients had given informed consent and were exposed to the risks of therapy. Responsibility for non-publication lies with investigators, but pharmaceutical companies, research ethics committees, journals and governments can all encourage the timely publication of trial data.

Magnetic resonance imaging versus computed tomography for detection of acute vascular lesions in patients presenting with stroke symptoms

BACKGROUND

Magnetic resonance imaging (MRI) is increasingly used for the diagnosis of acute ischaemic stroke but its sensitivity for the early detection of intracerebral haemorrhage has been debated. Computed tomography (CT) is extensively used in the clinical management of acute stroke, especially for the rapid exclusion of intracerebral haemorrhage.

OBJECTIVES

To compare the diagnostic accuracy of diffusion-weighted MRI (DWI) and CT for acute ischaemic stroke, and to estimate the diagnostic accuracy of MRI for acute haemorrhagic stroke.

SEARCH STRATEGY

We searched MEDLINE and EMBASE (January 1995 to March 2009) and perused bibliographies of relevant studies for additional references.

SELECTION CRITERIA

We selected studies that either compared DWI and CT in the same patients for detection of ischaemic stroke or examined the utility of MRI for detection of haemorrhagic stroke, had imaging performed within 12 hours of stroke onset, and presented sufficient data to allow construction of contingency tables.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data on study characteristics and measures of accuracy. We assessed data on ischaemic stroke using random-effects and fixed-effect meta-analyses.

MAIN RESULTS

Eight studies with a total of 308 participants met our inclusion criteria. Seven studies contributed to the assessment of ischaemic stroke and two studies to the assessment of haemorrhagic stroke. The spectrum of patients was relatively narrow in all studies, sample sizes were small, there was substantial incorporation bias, and blinding procedures were often incomplete. Amongst the patients subsequently confirmed to have acute ischaemic stroke (161/226), the summary estimates for DWI were: sensitivity 0.99 (95% CI 0.23 to 1.00), specificity 0.92 (95% CI 0.83 to 0.97). The summary estimates for CT were: sensitivity 0.39 (95% CI 0.16 to 0.69), specificity 1.00 (95% CI 0.94 to 1.00). The two studies on haemorrhagic stroke reported high estimates for diffusion-weighted and gradient-echo sequences but had inconsistent reference standards. We did not calculate overall estimates for these two studies. We were not able to assess practicality or cost-effectiveness issues.

AUTHORS' CONCLUSIONS

DWI appears to be more sensitive than CT for the early detection of ischaemic stroke in highly selected patients. However, the variability in the quality of included studies and the presence of spectrum and incorporation biases render the reliability and generalisability of observed results questionable. Further well-designed studies without methodological biases, in more representative patient samples, with practicality and cost estimates are now needed to determine which patients should undergo MRI and which CT in suspected acute stroke.

No evidence of bias in the process of publication of diagnostic accuracy studies in stroke submitted as abstracts

OBJECTIVE

There is little empirical evidence on publication bias in diagnostic test accuracy studies. We evaluated the proportion of abstracts presented at international stroke meetings, which were later published in full, and investigated which study features characterized publication.

METHODS

We reviewed all diagnostic abstracts presented at two international stroke conferences between 1995 and 2004. We assessed the characteristics and findings of the identified abstracts. We identified full publications through electronic databases and by contacting the authors. Determinants of publication were assessed by Cox regression.

RESULTS

Seventy-six percent (121 out of 160) of identified abstracts were subsequently published in full. Sixty-two percent were published within 24 months of presentation. The median time to publication was 16 months. Assessment of interobserver agreement between test readers was a significant predictor of full publication (P=0.02). No other study characteristic (including clinical utility of results, multicenter status, or Youden's index) was predictive.

CONCLUSIONS

We found no clear evidence of bias in the publication process that occurs after abstract acceptance. We were unable to assess bias in abstract submission or acceptance. "Interobserver agreement" was the only characteristic statistically associated with publication. Clinical utility of results and other study characteristics did not predict publication. Diagnostic abstracts often did not report many relevant methodological aspects.

Systematic review of the effectiveness and cost-effectiveness of HealOzone for the treatment of occlusal pit/fissure caries and root caries

OBJECTIVES

To assess the effectiveness and cost-effectiveness of HealOzone (CurOzone USA Inc., Ontario, Canada) for the management of pit and fissure caries, and root caries. The complete HealOzone procedure involves the direct application of ozone gas to the caries lesion on the tooth surface, the use of a remineralising solution immediately after application of ozone and the supply of a 'patient kit', which consists of toothpaste, oral rinse and oral spray all containing fluoride.

DATA SOURCES

Electronic databases up to May 2004 (except Conference Papers Index, which were searched up to May 2002).

REVIEW METHODS

A systematic review of the effectiveness of HealOzone for the management of tooth decay was carried out. A systematic review of existing economic evaluations of ozone for dental caries was also planned but no suitable studies were identified. The economic evaluation included in the industry submission was critically appraised and summarised. A Markov model was constructed to explore possible cost-effectiveness aspects of HealOzone in addition to current management of dental caries.

RESULTS

Five full-text reports and five studies published as abstracts met the inclusion criteria. The five full-text reports consisted of two randomised controlled trials (RCTs) assessing the use of HealOzone for the management of primary root caries and two doctoral theses of three unpublished randomised trials assessing the use of HealOzone for the management of occlusal caries. Of the abstracts, four assessed the effects of HealOzone for the management of occlusal caries and one the effects of HealOzone for the management of root caries. Overall, the quality of the studies was modest, with many important methodological aspects not reported (e.g. concealment of allocation, blinding procedures, compliance of patients with home treatment). In particular, there were some concerns about the choice of statistical analyses. In most of the full-text studies analyses were undertaken at lesion level, ignoring the clustering of lesions within patients. The nature of the methodological concerns was sufficient to raise doubts about the validity of the included studies' findings. A quantitative synthesis of results was deemed inappropriate. On the whole, there is not enough evidence from published RCTs on which to judge the effectiveness of ozone for the management of both occlusal and root caries. The perspective adopted for the study was that of the NHS and Personal Social Services. The analysis, carried out over a 5-year period, indicated that treatment using current management plus HealOzone cost more than current management alone for non-cavitated pit and fissure caries (40.49 pounds versus 24.78 pounds), but cost less for non-cavitated root caries ( 14.63 pounds versus 21.45 pounds). Given the limitations of the calculations these figures should be regarded as illustrative, not definitive. It was not possible to measure health benefits in terms of quality-adjusted life-years, due to uncertainties around the evidence of clinical effectiveness, and to the fact that the adverse events avoided are transient (e.g. pain from injection of local anaesthetic, fear of the drill). One-way sensitivity analysis was applied to the model. However, owing to the limitations of the economic analysis, this should be regarded as merely speculative. For non-cavitated pit and fissure caries, the HealOzone option was always more expensive than current management when the probability of cure using the HealOzone option was 70% or lower. For non-cavitated root caries the costs of the HealOzone comparator were lower than those of current management only when cure rates from HealOzone were at least 80%. The costs of current management were higher than those of the HealOzone option when the cure rate for current management was 40% or lower. One-way sensitivity analysis was also performed using similar NHS Statement of Dental Remuneration codes to those that are used in the industry submission. This did not alter the results for non-cavitated pit fissure caries as the discounted net present value of current management remained lower than that of the HealOzone comparator ( 22.65 pounds versus 33.39 pounds).

CONCLUSIONS

Any treatment that preserves teeth and avoids fillings is welcome. However, the current evidence base for HealOzone is insufficient to conclude that it is a cost-effective addition to the management and treatment of occlusal and root caries. To make a decision on whether HealOzone is a cost-effective alternative to current preventive methods for the management of dental caries, further research into its clinical effectiveness is required. Independent RCTs of the effectiveness and cost-effectiveness of HealOzone for the management of occlusal caries and root caries need to be properly conducted with adequate design, outcome measures and methods for statistical analyses.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons. Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review

PURPOSE

We systematically reviewed the evidence on the efficacy and safety of sacral nerve stimulation (SNS) for severe urge incontinence.

MATERIALS AND METHODS

A systematic review was performed of primary studies of SNS for urge incontinence published in English between 1966 and May 2003, and identified in major electronic databases. Two reviewers independently selected studies, assessed their methodological quality and extracted data.

RESULTS

Four randomized controlled trials and 30 case series were identified. Evidence from the randomized controlled trials, involving approximately 120 patients, showed that about 80% achieved continence or greater than 50% improvement in their main incontinence symptoms after SNS compared with about 3% of controls receiving conservative treatments while waiting for an implant. While case series were larger, they were methodologically less reliable. However, they showed similar results with 67% of patients becoming dry or achieving a greater than 50% improvement in symptoms after implantation. Incontinence episodes, leakage severity, voiding frequency and pad use were significantly lower after implantation. Benefits were reported to persist 3 to 5 years after implantation. Adverse events were documented in 27 studies. Overall the reoperation rate in implanted cases was 33%. The most common reason for surgical revision was relocation of the generator because of pain and infection. Common complications were pain at the implant or lead site in 25% of patients, lead related problems such as lead migration in 16%, replacement and repositioning of the implanted pulse generator in 15%, wound problems in 7%, adverse effects on bowel function in 6%, infection in 5% and generator problems in 5%. Permanent removal of the electrodes was reported in 9% of patients. Technical changes with time have been associated with decreased complication rates.

CONCLUSIONS

There is evidence indicating that SNS is effective for decreasing symptoms in patients with urge incontinence. Adverse events occurred in about half of the implanted cases and surgical revision was performed in 33%. No major irreversible complications were reported in the studies reviewed. Further research is required on the long-term effects of and quality of life in patients with SNS.

Systematic review of the prognostic effectiveness of SPECT myocardial perfusion scintigraphy in patients with suspected or known coronary artery disease and following myocardial infarction

OBJECTIVES

In patients with suspected or known coronary artery disease (CAD), or following myocardial infarction (MI), assessing the degree of ischaemia is important from a prognostic and therapeutic point of view. Single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) is a non-invasive technique that allows the presence, location and extent of ischaemia to be determined. The aim of this systematic review was to assess the prognostic effectiveness of SPECT MPS.

METHODS

We sought prognostic studies involving SPECT, exercise tolerance testing (ETT) and/or coronary angiography (CA) in people with suspected or known CAD, or following MI. Outcomes included cardiac death, non-fatal MI and revascularization. We searched the following databases: MEDLINE, PREMEDLINE, EMBASE, BIOSIS, Science Citation Index, the Cochrane Library, the Health Management Information Consortium and the Health Technology Assessment Database.

RESULTS

Twenty-one observational studies enrolling 53,762 people reported the general prognostic value of SPECT MPS. In multivariate analysis, SPECT MPS variables yielded both independent and incremental value to combinations of clinical, ETT and angiographic variables in predicting cardiac death or non-fatal MI. Three comparative studies reported lower revascularization rates following a SPECT MPS-CA strategy (6-21%) compared with direct CA (16-44%). Four observational studies enrolling 2106 people reported the prognostic value of SPECT for patients following MI. In multivariate analysis including clinical history, ETT, SPECT MPS and angiographic variables, strategies involving SPECT MPS provided independent and incremental prognostic performance in predicting future cardiac events.

CONCLUSIONS

SPECT MPS provides important additional information to that from ETT and/or CA that helps to risk-stratify patients with suspected or known CAD or following MI, enabling them to be managed more appropriately. Increasing the use of strategies involving SPECT MPS may identify lower risk patients for whom invasive CA might be avoided.

The effectiveness of metal on metal hip resurfacing: a systematic review of the available evidence published before 2002

Background

Conventional total hip replacement (THR) may be felt to carry too high a risk of failure over a patient's lifetime, especially in young people. There is increasing interest in metal on metal hip resurfacing arthroplasty (MoM) as this offers a bone-conserving option for treating those patients who are not considered eligible for THR. We aim to evaluate the effectiveness of MoM for treatment of hip disease, and compare it with alternative treatments for hip disease offered within the UK.

Methods

A systematic review was carried out to identify the relevant literature on MoM published before 2002. As watchful waiting and total hip replacement are alternative methods commonly used to alleviate the symptoms of degenerative joint disease of the hip, we compared MoM with these.

Results

The data on the effectiveness of MoM are scarce, as it is a relatively new technique and at present only short-term results are available.

Conclusion

It is not possible to make any firm conclusions about the effectiveness of MoM based on these early results. While the short-term results are promising, it is unclear if such results would be replicated in more rigorous studies, and what the long-term performance might be. Further research is needed which ideally should involve long-term randomised comparisons of MoM with alternative approaches to the clinical management of hip disease.

Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction

OBJECTIVES

To assess the effectiveness and cost-effectiveness of single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction (MI).

DATA SOURCES

Major electronic databases.

REVIEW METHODS

Two reviewers independently extracted data and assessed study quality. A decision tree model was used to model the diagnosis decision and a Markov model was developed for the management of patients with suspected coronary artery disease. Costs for the treatments and interventions within strategies were derived from the literature and expressed in 2001-02 pounds sterling. Quality-adjusted life-year (QALY) weights for the different Markov model states were also obtained from the literature.

RESULTS

Twenty-one diagnostic and 46 prognostic studies were included, plus two studies comparing SPECT with electrocardiography (ECG)-gated SPECT and one study comparing SPECT with attenuation-corrected SPECT. The diagnostic values of SPECT were generally higher than those of stress ECG, indicating that SPECT provided a better diagnostic performance. SPECT also provided higher positive and lower negative likelihood ratios than stress ECG but heterogeneity was evident among studies. The subgroup of studies including patients with previous MI tended to report a better diagnostic performance for SPECT than stress ECG, but there were too few studies to assess this reliably. The extent and size of the perfusion defect, and whether reversible or fixed, were important factors in predicting future cardiac events such as cardiac death or non-fatal MI. SPECT may be able to identify lower risk patients for whom coronary angiography (CA) might be avoided. Normal SPECT scans were associated with a benign prognosis and the option of medical rather than invasive management. Four studies of patients post-MI reported SPECT to be valuable in stratifying patients into at-risk groups for further cardiac events. The two studies comparing SPECT with ECG-gated SPECT, one diagnostic and the other prognostic, found in favour of gated SPECT. The study comparing SPECT with attenuation-corrected SPECT reported the latter to be more accurate. The systematic review of economic evaluations indicated that strategies involving SPECT were likely either to be dominant or to produce more QALYs at an acceptable cost. There was less agreement about which of the strategies involving SPECT was optimal. The model suggested that, for low prevalence, the incremental cost per unit of output (true positives diagnosed, accurate diagnosis, QALY) for the move from stress ECG-SPECT-CA and from stress ECG-CA to SPECT-CA might be considered worthwhile. Even after allowing for different values for sensitivity or specificity, the least costly and least effective strategy was stress ECG-SPECT-CA. The sensitivity analysis suggested that the cost-effectiveness of SPECT-CA improved if it was assumed that SPECT results allowed for the adoption of a management strategy without recourse to CA. As the time horizon reduced, the incremental cost per QALY increased (as the cost of initial diagnosis and treatment were not offset by survival and quality of life gains).

CONCLUSIONS

There was a considerable variability in terms of measurement of outcomes, management, setting and patient characteristics, however the direction of evidence tended to favour SPECT in terms of test sensitivity, although these conclusions are based on a relatively small number of diagnostic studies. SPECT, in a variety of settings and patient populations, provided valuable independent and incremental prognostic information to that provided by stress ECG and/or CA that helped to risk-stratify patients and influence the way in which their condition was managed. However, all of the prognostic studies were observational studies and may be biased by unknown confounding factors. Although the ECG-gated and attenuation-corrected SPECT findings seem promising, it is difficult to draw conclusions from so few studies. Further research is needed on the effectiveness and cost-effectiveness, diagnostically and prognostically, of (a) gated and attenuation-corrected SPECT compared with standard SPECT, (b) standard SPECT compared with stress echocardiography and (c) the uncertainty surrounding the results presented in the cost-effectiveness analysis.

Drug treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a common symptom which causes significant distress and reduction in quality of life. Available treatment options for faecal incontinence include conservative treatments (biofeedback, pelvic floor muscle training, dietary manipulation or drug therapy) or surgical treatments (e.g. sphincter repair, post anal repair, neosphincter). Drug treatment is often given either alone or in combination with other treatment modalities.

OBJECTIVES

To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2003) and the reference lists of relevant articles. Date of the most recent search: January 2003.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of the use of pharmacological agents for the treatment of faecal incontinence in adults.

DATA COLLECTION AND ANALYSIS

Working independently, reviewers selected studies from the literature, assessed the methodological quality of each trial, and extracted data.

MAIN RESULTS

Eleven trials were identified for inclusion in this review. Nine trials were of cross-over design. Seven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea or following ileoanal pouch surgery). Three trials (total 58 participants) compared topical phenylephrine gel with placebo. Two trials (56 participants) compared loperamide with placebo. One trial (11 participants) compared loperamide oxide with placebo. One trial (15 participants) compared diphenoxylate plus atropine with placebo. One trial (17 participants) compared sodium valproate with placebo. One trial (30 participants) compared loperamide with codeine with diphenoxylate plus atropine. Two further trials (total 265 participants) assessed the use of lactulose in elderly people.No studies comparing drugs with other treatment modalities were identified. There was limited evidence that antidiarrhoeal drugs and drugs which enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. However, the trials were small and of short duration.

REVIEWER'S CONCLUSIONS

The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which include clinically important outcome measures, are required.

Absorbent products for containing urinary and/or fecal incontinence in adults

OBJECTIVES

The objectives of this study were to assess the effectiveness and cost-effectiveness of different types of absorbent product for people with incontinence.

DESIGN

A systematic review of randomized and quasi-randomized controlled trials was performed to compare different types of absorbent products for the containment of urinary and/or fecal incontinence in adults.

SETTING AND METHODS

Randomized and quasi-randomized trials available by March 2000 were used. Trials were identified through searches of major bibliographic and research databases. Investigators in the field were also contacted to locate studies.

SUBJECTS

The trials reviewed comprised a total of 345 participants.

RESULTS

Five trials were identified. The following comparisons were considered: disposable versus nondisposable pad-and-pant systems or all-in-one diapers (bodyworns), disposable versus nondisposable underpads, bodyworns versus underpads, and superabsorbent versus fluff-pulp products. Outcomes and type of intervention were heterogeneous among trials. Combining data from more than one trial proved to be impracticable. In a single trial, fewer people who used disposable products complained of skin problems compared with those who used nondisposable products (odds ratio, 0.08; 95% confidence interval 0.03 to 0.20). Similarly, people who used superabsorbent products experienced less severe skin problems than those who used fluff pulp products (P <.03).

CONCLUSIONS

The data were too few and of insufficient quality to provide a firm basis for practice. However, the data suggest that disposable products are more costly but more effective than nondisposable products in decreasing the incidence of skin problems and that superabsorbent products perform better than fluff pulp products.