Effectiveness of paediatric asthma clinical pathways: a narrative systematic review

OBJECTIVE

To evaluate the effectiveness of clinical pathways (CPs) for paediatric asthma on length of hospital stay, additional visits due to asthma exacerbations, hospital cost, manpower and workload required for implementing CPs.

METHODS

Studies were eligible if they met the following criteria: children (≦18 years) with asthma, hospital or emergency department based, and study designs were (1) randomised controlled trial, (2) controlled clinical trial or (3) controlled before and after study. Two reviewers independently screened references, extracted data and assessed the risk of bias. We resolved disagreement by discussion between authors. Due to an insufficient number of studies and the heterogeneity of interventions and outcomes, we conducted a narrative systematic review with forest plots but did not pool results.

RESULTS

About 3155 relevant articles were identified through a literature search, 628 were duplicates removed, 2037 were excluded based on review of titles and abstracts and 117 were excluded because they did not meet inclusion criteria. Seven studies involving 2600 participants met the inclusion criteria. Using asthma CPs may decrease the length of hospital stay; however, CPs did not appear to reduce additional visits due to asthma exacerbations or reduce hospital costs. No eligible studies were found that quantified the manpower and workload for implementing CPs.

CONCLUSIONS

Current studies suggest CPs may reduce the length of hospital stay, but insufficient evidence is available on total costs or readmissions to justify extensive uptake of asthma CPs in paediatric inpatient care. Higher quality, large randomised controlled trials are required that measure costs and a wider range of outcomes.

Which lipid measurement should we monitor? An analysis of the LIPID study

OBJECTIVES

To evaluate the optimal lipid to measure in monitoring patients, we assessed three factors that influence the choice of monitoring tests: (1) clinical validity; (2) responsiveness to therapy changes and (3) the size of the long-term 'signal-to-noise' ratio.

DESIGN

Longitudinal analyses of repeated lipid measurement over 5 years.

SETTING

Subsidiary analysis of a Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) study-a clinical trial in Australia, New Zealand and Finland.

PARTICIPANTS

9014 patients aged 31-75 years with previous acute coronary syndromes.

INTERVENTIONS

Patients were randomly assigned to 40 mg daily pravastatin or placebo.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used data on serial lipid measurements-at randomisation, 6 months and 12 months, and then annually to 5 years-of total cholesterol; low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and their ratios; triglycerides; and apolipoproteins A and B and their ratio and their ability to predict coronary events.

RESULTS

All the lipid measures were statistically significantly associated with future coronary events, but the associations between each of the three ratio measures (total or LDL cholesterol to HDL cholesterol, and apolipoprotein B to apolipoprotein A1) and the time to a coronary event were better than those for any of the single lipid measures. The two cholesterol ratios also ranked highly for the long-term signal-to-noise ratios. However, LDL cholesterol and non-HDL cholesterol showed the most responsiveness to treatment change.

CONCLUSIONS

Lipid monitoring is increasingly common, but current guidelines vary. No single measure was best on all three criteria. Total cholesterol did not rank highly on any single criterion. However, measurements based on cholesterol subfractions-non-HDL cholesterol (total cholesterol minus HDL cholesterol) and the two ratios-appeared superior to total cholesterol or any of the apolipoprotein options. Guidelines should consider using non-HDL cholesterol or a ratio measure for initial treatment decisions and subsequent monitoring.

Antibiotics for sore throat

BACKGROUND

Sore throat is a common reason for people to present for medical care. Although it remits spontaneously, primary care doctors commonly prescribe antibiotics for it.

OBJECTIVES

To assess the benefits of antibiotics for sore throat for patients in primary care settings.

SEARCH METHODS

We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to July week 1, 2013) and EMBASE (January 1990 to July 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. We contacted trial authors from three studies for additional information.

MAIN RESULTS

We included 27 trials with 12,835 cases of sore throat. We did not identify any new trials in this 2013 update. 1. Symptoms Throat soreness and fever were reduced by about half by using antibiotics. The greatest difference was seen at day three. The number needed to treat to benefit (NNTB) to prevent one sore throat at day three was less than six; at week one it was 21. 2. Non-suppurative complications The trend was antibiotics protecting against acute glomerulonephritis but there were too few cases to be sure. Several studies found antibiotics reduced acute rheumatic fever by more than two-thirds within one month (risk ratio (RR) 0.27; 95% confidence interval (CI) 0.12 to 0.60). 3. Suppurative complications Antibiotics reduced the incidence of acute otitis media within 14 days (RR 0.30; 95% CI 0.15 to 0.58); acute sinusitis within 14 days (RR 0.48; 95% CI 0.08 to 2.76); and quinsy within two months (RR 0.15; 95% CI 0.05 to 0.47) compared to those taking placebo. 4. Subgroup analyses of symptom reduction Antibiotics were more effective against symptoms at day three (RR 0.58; 95% CI 0.48 to 0.71) if throat swabs were positive for Streptococcus, compared to RR 0.78; 95% CI 0.63 to 0.97 if negative. Similarly at week one the RR was 0.29 (95% CI 0.12 to 0.70) for positive and 0.73 (95% CI 0.50 to 1.07) for negative Streptococcus swabs.

AUTHORS' CONCLUSIONS

Antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest. Protecting sore throat sufferers against suppurative and non-suppurative complications in high-income countries requires treating many with antibiotics for one to benefit. This NNTB may be lower in low-income countries. Antibiotics shorten the duration of symptoms by about 16 hours overall.

Criteria for monitoring tests were described: validity, responsiveness, detectability of long-term change, and practicality

OBJECTIVES

To describe how evidence from trials and cohort studies may be used to guide choice of test for monitoring patients with chronic disease.

STUDY DESIGN AND SETTING

Exploration of potential criteria for choosing the best monitoring test. Criteria are defined and options for assessment measures for test performance on each criterion discussed.

RESULTS

Monitoring in clinical practice occurs in three main phases: before treatment, response to treatment, and long-term monitoring. Four important criteria may be used to choose the best test for monitoring a patient in each of these phases. Clinical validity describes the ability of the test to predict the clinically relevant outcome that we are trying to control or prevent. Responsiveness describes how much the test changes in response to an intervention relative to background random variation. Detectability of long-term change describes the size of changes in the test over the long term relative to background random variation. Practicality describes the ease of use, invasiveness, and cost of the test. Test performance generally requires longitudinal data from trial and/or cohort studies using statistical methods such as those discussed.

CONCLUSION

Four specific criteria can help clinicians inform evidence-based decisions on which monitoring test to use.

Poor description of non-pharmacological interventions: analysis of consecutive sample of randomised trials

OBJECTIVES

To evaluate the completeness of descriptions of non-pharmacological interventions in randomised trials, identify which elements are most frequently missing, and assess whether authors can provide missing details.

DESIGN

Analysis of consecutive sample of randomised trials of non-pharmacological interventions.

DATA SOURCES AND STUDY SELECTION

All reports of randomised trials of non-pharmacological interventions published in 2009 in six leading general medical journals; 133 trial reports, with 137 interventions, met the inclusion criteria.

DATA COLLECTION

Using an eight item checklist, two raters assessed the primary full trial report, plus any reference materials, appendices, or websites. Questions about missing details were emailed to corresponding authors, and relevant items were then reassessed.

RESULTS

Of 137 interventions, only 53 (39%) were adequately described; this was increased to 81 (59%) by using 63 responses from 88 contacted authors. The most frequently missing item was the "intervention materials" (47% complete), but it also improved the most after author response (92% complete). Whereas some authors (27/70) provided materials or further information, other authors (21/70) could not; their reasons included copyright or intellectual property concerns, not having the materials or intervention details, or being unaware of their importance. Although 46 (34%) trial interventions had further information or materials readily available on a website, many were not mentioned in the report, were not freely accessible, or the URL was no longer functioning.

CONCLUSIONS

Missing essential information about interventions is a frequent, yet remediable, contributor to the worldwide waste in research funding. If trial reports do not have a sufficient description of interventions, other researchers cannot build on the findings, and clinicians and patients cannot reliably implement useful interventions. Improvement will require action by funders, researchers, and publishers, aided by long term repositories of materials linked to publications.

Expanding disease definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States

BACKGROUND

Financial ties between health professionals and industry may unduly influence professional judgments and some researchers have suggested that widening disease definitions may be one driver of over-diagnosis, bringing potentially unnecessary labeling and harm. We aimed to identify guidelines in which disease definitions were changed, to assess whether any proposed changes would increase the numbers of individuals considered to have the disease, whether potential harms of expanding disease definitions were investigated, and the extent of members' industry ties.

METHODS AND FINDINGS

We undertook a cross-sectional study of the most recent publication between 2000 and 2013 from national and international guideline panels making decisions about definitions or diagnostic criteria for common conditions in the United States. We assessed whether proposed changes widened or narrowed disease definitions, rationales offered, mention of potential harms of those changes, and the nature and extent of disclosed ties between members and pharmaceutical or device companies. Of 16 publications on 14 common conditions, ten proposed changes widening and one narrowing definitions. For five, impact was unclear. Widening fell into three categories: creating "pre-disease"; lowering diagnostic thresholds; and proposing earlier or different diagnostic methods. Rationales included standardising diagnostic criteria and new evidence about risks for people previously considered to not have the disease. No publication included rigorous assessment of potential harms of proposed changes. Among 14 panels with disclosures, the average proportion of members with industry ties was 75%. Twelve were chaired by people with ties. For members with ties, the median number of companies to which they had ties was seven. Companies with ties to the highest proportions of members were active in the relevant therapeutic area. Limitations arise from reliance on only disclosed ties, and exclusion of conditions too broad to enable analysis of single panel publications.

CONCLUSIONS

For the common conditions studied, a majority of panels proposed changes to disease definitions that increased the number of individuals considered to have the disease, none reported rigorous assessment of potential harms of that widening, and most had a majority of members disclosing financial ties to pharmaceutical companies. Please see later in the article for the Editors' Summary.

Autoinflation for hearing loss associated with otitis media with effusion

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2006.Otitis media with effusion (OME) or 'glue ear' is an accumulation of fluid in the middle ear, in the absence of acute inflammation or infection. It is the commonest cause of acquired hearing loss in childhood and the usual reason for insertion of 'grommets'. Potential treatments include decongestants, mucolytics, steroids, antihistamines and antibiotics. Autoinflation devices have been proposed as a simple mechanical means of improving 'glue ear'.

OBJECTIVES

To assess the effectiveness of autoinflation compared with no treatment in children and adults with otitis media with effusion.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 April 2013.

SELECTION CRITERIA

We selected randomised controlled trials that compared any form of autoinflation to no autoinflation in individuals with 'glue ear'.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted data from included studies.

MAIN RESULTS

Eight studies, with a total of 702 participants, met the inclusion criteria. Overall, the studies were predominantly assessed as being at low or unclear risk of bias; unclear risk was mainly due lack of information. There was no evidence of selective reporting.Pooled estimates favoured the intervention, but did not show a significant effect on tympanometry (type C2 and B) at less than one month, nor at more than one month. Similarly, there were no significant changes for discrete pure-tone audiometry and non-discrete audiometry. Pooled estimates favoured, but not significantly, the intervention for the composite measure of tympanogram or audiometry at less than one month; at more than one month the result became significant (RRI 1.74, 95% CI 1.22 to 2.50). Subgroup analysis based on the type of intervention showed a significant effect using a Politzer device under one month (RRI 7.07, 95% CI 3.70 to 13.51) and over one month (RRI 2.25, 95% CI 1.67 to 3.04).None of the studies demonstrated a significant difference in the incidence of side effects between interventions.

AUTHORS' CONCLUSIONS

All of the studies were small, of limited treatment duration and had short follow-up. However, because of the low cost and absence of adverse effects it is reasonable to consider autoinflation whilst awaiting natural resolution of otitis media with effusion. Primary care could prove a beneficial place to evaluate such interventions and there is ongoing research in this area. Further research should also consider the duration of treatment, the long-term impact on developmental outcomes in children and additional quality of life outcome measures for children and families.

Are systematic reviews up-to-date at the time of publication?

BACKGROUND

Systematic reviews provide a synthesis of evidence for practitioners, for clinical practice guideline developers, and for those designing and justifying primary research. Having an up-to-date and comprehensive review is therefore important. Our main objective was to determine the recency of systematic reviews at the time of their publication, as measured by the time from last search date to publication. We also wanted to study the time from search date to acceptance, and from acceptance to publication, and measure the proportion of systematic reviews with recorded information on search dates and information sources in the abstract and full text of the review.

METHODS

A descriptive analysis of published systematic reviews indexed in Medline in 2009, 2010 and 2011 by three reviewers, independently extracting data.

RESULTS

Of the 300 systematic reviews included, 271 (90%) provided the date of search in the full-text article, but only 141 (47%) stated this in the abstract. The median (standard error; minimum to maximum) survival time from last search to acceptance was 5.1 (0.58; 0 to 43.8) months (95% confidence interval = 3.9 to 6.2) and from last search to first publication time was 8.0 (0.35; 0 to 46.7) months (95% confidence interval = 7.3 to 8.7), respectively. Of the 300 reviews, 295 (98%) stated which databases had been searched, but only 181 (60%) stated the databases in the abstract. Most researchers searched three (35%) or four (21%) databases. The top-three most used databases were MEDLINE (79%), Cochrane library (76%), and EMBASE (64%).

CONCLUSIONS

Being able to identify comprehensive, up-to-date reviews is important to clinicians, guideline groups, and those designing clinical trials. This study demonstrates that some reviews have a considerable delay between search and publication, but only 47% of systematic review abstracts stated the last search date and 60% stated the databases that had been searched. Improvements in the quality of abstracts of systematic reviews and ways to shorten the review and revision processes to make review publication more rapid are needed.

Antibiotics for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is one of the most common diseases in early infancy and childhood. Antibiotic use for AOM varies from 56% in the Netherlands to 95% in the USA, Canada and Australia.

OBJECTIVES

To assess the effects of antibiotics for children with AOM.

SEARCH METHODS

We searched CENTRAL (2012, Issue 10), MEDLINE (1966 to October week 4, 2012), OLDMEDLINE (1958 to 1965), EMBASE (January 1990 to November 2012), Current Contents (1966 to November 2012), CINAHL (2008 to November 2012) and LILACS (2008 to November 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing 1) antimicrobial drugs with placebo and 2) immediate antibiotic treatment with expectant observation (including delayed antibiotic prescribing) in children with AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

For the review of antibiotics against placebo, 12 RCTs (3317 children and 3854 AOM episodes) from high-income countries were eligible. However, one trial did not report patient-relevant outcomes, leaving 11 trials with generally low risk of bias. Pain was not reduced by antibiotics at 24 hours (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.78 to 1.01) but almost a third fewer had residual pain at two to three days (RR 0.70; 95% CI 0.57 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) 20) and fewer had pain at four to seven days (RR 0.79; 95% CI 0.66 to 0.95; NNTB 20). When compared with placebo, antibiotics did not alter the number of abnormal tympanometry findings at either four to six weeks (RR 0.92; 95% CI 0.83 to 1.01) or at three months (RR 0.97; 95% CI 0.76 to 1.24), or the number of AOM recurrences (RR 0.93; 95% CI 0.78 to 1.10). However, antibiotic treatment did lead to a statistically significant reduction of tympanic membrane perforations (RR 0.37; 95% CI 0.18 to 0.76; NNTB 33) and halved contralateral AOM episodes (RR 0.49; 95% CI 0.25 to 0.95; NNTB 11) as compared with placebo. Severe complications were rare and did not differ between children treated with antibiotics and those treated with placebo. Adverse events (such as vomiting, diarrhoea or rash) occurred more often in children taking antibiotics (RR 1.34; 95% CI 1.16 to 1.55; number needed to treat for an additional harmful outcome (NNTH) 14). Funnel plots do not suggest publication bias. Individual patient data meta-analysis of a subset of included trials found antibiotics to be most beneficial in children aged less than two with bilateral AOM, or with both AOM and otorrhoea.For the review of immediate antibiotics against expectant observation, five trials (1149 children) were eligible. Four trials (1007 children) reported outcome data that could be used for this review. From these trials, data from 959 children could be extracted for the meta-analysis on pain at days three to seven. No difference in pain was detectable at three to seven days (RR 0.75; 95% CI 0.50 to 1.12). No serious complications occurred in either the antibiotic group or the expectant observation group. Additionally, no difference in tympanic membrane perforations and AOM recurrence was observed. Immediate antibiotic prescribing was associated with a substantial increased risk of vomiting, diarrhoea or rash as compared with expectant observation (RR 1.71; 95% CI 1.24 to 2.36).

AUTHORS' CONCLUSIONS

Antibiotic treatment led to a statistically significant reduction of children with AOM experiencing pain at two to seven days compared with placebo but since most children (82%) settle spontaneously, about 20 children must be treated to prevent one suffering from ear pain at two to seven days. Additionally, antibiotic treatment led to a statistically significant reduction of tympanic membrane perforations (NNTB 33) and contralateral AOM episodes (NNTB 11). These benefits must be weighed against the possible harms: for every 14 children treated with antibiotics, one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics had been withheld. Antibiotics appear to be most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease, an expectant observational approach seems justified. We have no trials in populations with higher risks of complications.

Antibiotics for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is one of the most common diseases in early infancy and childhood. Antibiotic use for AOM varies from 56% in the Netherlands to 95% in the USA, Canada and Australia.

OBJECTIVES

To assess the effects of antibiotics for children with AOM.

SEARCH METHODS

We searched CENTRAL (2012, Issue 10), MEDLINE (1966 to October week 4, 2012), OLDMEDLINE (1958 to 1965), EMBASE (January 1990 to November 2012), Current Contents (1966 to November 2012), CINAHL (2008 to November 2012) and LILACS (2008 to November 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing 1) antimicrobial drugs with placebo and 2) immediate antibiotic treatment with expectant observation (including delayed antibiotic prescribing) in children with AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

For the review of antibiotics against placebo, 12 RCTs (3317 children and 3854 AOM episodes) from high-income countries were eligible. However, one trial did not report patient-relevant outcomes, leaving 11 trials with generally low risk of bias. Pain was not reduced by antibiotics at 24 hours (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.78 to 1.01) but almost a third fewer had residual pain at two to three days (RR 0.70; 95% CI 0.57 to 0.86; number needed to treat for an additional beneficial outcome (NNTB) 20) and fewer had pain at four to seven days (RR 0.79; 95% CI 0.66 to 0.95; NNTB 20). When compared with placebo, antibiotics did not alter the number of abnormal tympanometry findings at either four to six weeks (RR 0.92; 95% CI 0.83 to 1.01) or at three months (RR 0.97; 95% CI 0.76 to 1.24), or the number of AOM recurrences (RR 0.93; 95% CI 0.78 to 1.10). However, antibiotic treatment did lead to a statistically significant reduction of tympanic membrane perforations (RR 0.37; 95% CI 0.18 to 0.76; NNTB 33) and halved contralateral AOM episodes (RR 0.49; 95% CI 0.25 to 0.95; NNTB 11) as compared with placebo. Severe complications were rare and did not differ between children treated with antibiotics and those treated with placebo. Adverse events (such as vomiting, diarrhoea or rash) occurred more often in children taking antibiotics (RR 1.34; 95% CI 1.16 to 1.55; number needed to treat for an additional harmful outcome (NNTH) 14). Funnel plots do not suggest publication bias. Individual patient data meta-analysis of a subset of included trials found antibiotics to be most beneficial in children aged less than two with bilateral AOM, or with both AOM and otorrhoea.For the review of immediate antibiotics against expectant observation, five trials (1149 children) were eligible. Four trials (1007 children) reported outcome data that could be used for this review. From these trials, data from 959 children could be extracted for the meta-analysis on pain at days three to seven. No difference in pain was detectable at three to seven days (RR 0.75; 95% CI 0.50 to 1.12). No serious complications occurred in either the antibiotic group or the expectant observation group. Additionally, no difference in tympanic membrane perforations and AOM recurrence was observed. Immediate antibiotic prescribing was associated with a substantial increased risk of vomiting, diarrhoea or rash as compared with expectant observation (RR 1.71; 95% CI 1.24 to 2.36).

AUTHORS' CONCLUSIONS

Antibiotic treatment led to a statistically significant reduction of children with AOM experiencing pain at two to seven days compared with placebo but since most children (82%) settle spontaneously, about 20 children must be treated to prevent one suffering from ear pain at two to seven days. Additionally, antibiotic treatment led to a statistically significant reduction of tympanic membrane perforations (NNTB 33) and contralateral AOM episodes (NNTB 11). These benefits must be weighed against the possible harms: for every 14 children treated with antibiotics, one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics had been withheld. Antibiotics appear to be most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease, an expectant observational approach seems justified. We have no trials in populations with higher risks of complications.

PRISMA for Abstracts: reporting systematic reviews in journal and conference abstracts

Elaine Beller and colleagues from the PRISMA for Abstracts group provide a reporting guidelines for reporting abstracts of systematic reviews in journals and at conferences.

Improving effectiveness of clinical medicine: the need for better translation of science into practice

Published research evidence does not automatically diffuse into clinical practice but requires active processes of translation that start with clinicians' awareness of the science and end with patient adherence to the recommended care. Many barriers thwart the uptake of valid and clinically important research into practice, with cognitive, motivational and sociological factors on the part of health professionals being among the most important. Encouraging clinicians to question the level of scientific certainty underpinning clinical practice and to actively seek evidence that may better inform clinical decisions is a priority for improving health care effectiveness. Although there are effective strategies for improving translation of research into practice, implementing them requires agreement between and buy-in from professional and managerial stakeholders.

Optimal screening interval for intraocular pressure measurement for Asian glaucoma patients

AIM: To explore the optimal interval of intraocular pressure (IOP) measurement for screening glaucoma in healthy people.

METHODS: From January to December 2005, we consecutively enrolled all participants (> 20 years old) attending the Center for Preventive Medicine at St. Luke’s International Hospital in Tokyo, Japan, for the annual health check program. The program promoted the early detection of chronic diseases and their risk factors. We excluded people who had glaucoma or a high IOP (≥ 22 mmHg) at baseline. The annual health check-ups collected all demographic information and medical history with an initial evaluation, including IOP measurement. IOP was measured in both eyes with a full auto-tonometer TX-F (Canon, Tokyo, Japan). Participants with an IOP ≥ 22 mmHg in either eye were considered to require additional evaluation for glaucoma. We divided the participants into two groups based on age: under 65 years old and over 65 years old. The United States Department of Health and Human Services Centers for Medicare and Medicaid Services guideline was used as a reference.

RESULTS: From January 2005 to July 2008, 12 385 participants underwent check-ups each year. The mean ± SD IOP in the higher eye at baseline was 13.4 (2.6) in 2005, 13.2 (2.7) in 2006, 13.3 (2.6), and 12.8 (2.6) in 2008. In addition, we analyzed the differences with an analysis of variance (ANOVA), and additional analysis was performed with Bonferroni’s correction. The difference between the 4 years was significant (P < 0.01) with ANOVA. Bonferroni analysis revealed significant differences between 2005 and 2006 (P < 0.01), 2005 and 2008 (P < 0.01), 2006 and 2007 (P < 0.01), 2006 and 2008 (P < 0.01), and 2007 and 2008 (P < 0.01). Only the difference between 2005 and 2007 was not significant (P = 0.1). Logistic regression suggested that only age (P < 0.01) and baseline IOP (P < 0.01) were associated with high IOP; the presence of diabetes, HgbA1c level, gender, systolic blood pressure, diastolic blood pressure, low-density lipoprotein and family history were non-significant.

CONCLUSION: Annual IOP check-ups may be recommended for participants aged ≥ 65 years with baseline IOPs of 17-21 mmHg. A check-up every 3 years or more may be recommended for patients with IOPs < 17 mmHg.

New treatments compared to established treatments in randomized trials

BACKGROUND

The proportion of proposed new treatments that are 'successful' is of ethical, scientific, and public importance. We investigated how often new, experimental treatments evaluated in randomized controlled trials (RCTs) are superior to established treatments.

OBJECTIVES

Our main question was: "On average how often are new treatments more effective, equally effective or less effective than established treatments?" Additionally, we wanted to explain the observed results, i.e. whether the observed distribution of outcomes is consistent with the 'uncertainty requirement' for enrollment in RCTs. We also investigated the effect of choice of comparator (active versus no treatment/placebo) on the observed results.

SEARCH METHODS

We searched the Cochrane Methodology Register (CMR) 2010, Issue 1 in The Cochrane Library (searched 31 March 2010); MEDLINE Ovid 1950 to March Week 2 2010 (searched 24 March 2010); and EMBASE Ovid 1980 to 2010 Week 11 (searched 24 March 2010).

SELECTION CRITERIA

Cohorts of studies were eligible for the analysis if they met all of the following criteria: (i) consecutive series of RCTs, (ii) registered at or before study onset, and (iii) compared new against established treatments in humans.

DATA COLLECTION AND ANALYSIS

RCTs from four cohorts of RCTs met all inclusion criteria and provided data from 743 RCTs involving 297,744 patients. All four cohorts consisted of publicly funded trials. Two cohorts involved evaluations of new treatments in cancer, one in neurological disorders, and one for mixed types of diseases. We employed kernel density estimation, meta-analysis and meta-regression to assess the probability of new treatments being superior to established treatments in their effect on primary outcomes and overall survival.

MAIN RESULTS

The distribution of effects seen was generally symmetrical in the size of difference between new versus established treatments. Meta-analytic pooling indicated that, on average, new treatments were slightly more favorable both in terms of their effect on reducing the primary outcomes (hazard ratio (HR)/odds ratio (OR) 0.91, 99% confidence interval (CI) 0.88 to 0.95) and improving overall survival (HR 0.95, 99% CI 0.92 to 0.98). No heterogeneity was observed in the analysis based on primary outcomes or overall survival (I(2) = 0%). Kernel density analysis was consistent with the meta-analysis, but showed a fairly symmetrical distribution of new versus established treatments indicating unpredictability in the results. This was consistent with the interpretation that new treatments are only slightly superior to established treatments when tested in RCTs. Additionally, meta-regression demonstrated that results have remained stable over time and that the success rate of new treatments has not changed over the last half century of clinical trials. The results were not significantly affected by the choice of comparator (active versus placebo/no therapy).

AUTHORS' CONCLUSIONS

Society can expect that slightly more than half of new experimental treatments will prove to be better than established treatments when tested in RCTs, but few will be substantially better. This is an important finding for patients (as they contemplate participation in RCTs), researchers (as they plan design of the new trials), and funders (as they assess the 'return on investment'). Although we provide the current best evidence on the question of expected 'success rate' of new versus established treatments consistent with a priori theoretical predictions reflective of 'uncertainty or equipoise hypothesis', it should be noted that our sample represents less than 1% of all available randomized trials; therefore, one should exercise the appropriate caution in interpretation of our findings. In addition, our conclusion applies to publicly funded trials only, as we did not include studies funded by commercial sponsors in our analysis.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids for symptoms of sore throat in adults and children.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 5) which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects and the NHS Health Economics Database, MEDLINE (1966 to November Week 4, 2012) and EMBASE (1974 to June 2012).

SELECTION CRITERIA

We included randomised controlled trials that compared steroids to either placebo or standard care in adults and children (older than three years of age) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis, sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality, and extracted relevant data.

MAIN RESULTS

We included eight trials involving 743 participants (369 children and 374 adults). All trials gave antibiotics to both placebo and corticosteroid groups; no trials assessed corticosteroids as standalone treatment for sore throat. In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by more than three times (risk ratio (RR) 3.2, 95% confidence interval (CI) 2.0 to 5.1, P < 0.001, I(2) statistic 44%) and at 48 hours by 1.7 times. Fewer than four people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 14 hours, respectively, although significant heterogeneity was present. At 24 hours, pain (assessed by visual analogue scores) was reduced by an additional 14% by corticosteroids. No difference in rates of recurrence, relapse or adverse events were reported for participants taking corticosteroids compared to placebo, although reporting of adverse events was poor.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, increase the likelihood of both resolution and improvement of pain in participants with sore throat. Further trials assessing corticosteroids in the absence of antibiotics and in children are warranted.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self-limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on clinical response rates in children and adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 5 which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) 2012, Issue 4 and the NHS Health Economics Database 2012, Issue 5; MEDLINE (1948 to May week 2, 2012) and EMBASE (January 2010 to May 2012).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead analysed results using narrative description of the available evidence.

MAIN RESULTS

We included two trials (253 participants). Both compared intranasal corticosteroids to placebo; no trials studied oral corticosteroids. No benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. In one trial of 54 participants, the number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P = 0.72). A second trial of 199 participants reported no significant differences in duration of symptoms. There were no differences reported in terms of: adverse events; complications (one case of sinusitis, one case of acute otitis media, both in corticosteroid groups); presence of rhinovirus in nasal aspirates; or treatment for secondary infections. Neither trial reported our primary outcome measure of percentage of participants with resolution at different time points. A lack of comparable outcome measures meant we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only two trials and limited statistical power. Further large randomised placebo-controlled trials in adults and children are required to answer this question.

Improving the effectiveness of clinical medicine: the need for better science

Effective clinical practice is predicated on valid and relevant clinical science - a commodity in increasingly short supply. The pre-eminent place of clinical research has become tainted by methodological shortcomings, commercial influences and neglect of the needs of patients and clinicians. Researchers need to be more proactive in evaluating clinical interventions in terms of patient-important benefit, wide applicability and comparative effectiveness, and in adopting study designs and reporting standards that ensure accurate and transparent research outputs. Funders of research need to be more supportive of applied clinical research that rigorously evaluates effectiveness of new treatments and synthesis existing knowledge into clinically useful systematic reviews. Several strategies for improving the state of the science are possible but their implementation requires collective action of all those undertaking and reporting clinical research.

Optimal prostate-specific antigen screening interval for prostate cancer

BACKGROUND

To identify the optimal interval for repeat prostate-specific antigen (PSA) testing to screen for prostate cancer in healthy adults.

PATIENTS AND METHODS

A retrospective cohort study was conducted on 7332 healthy males without prostate cancer at baseline from 2005 to 2008. Participants underwent annual health checkups including PSA testing at the Center for Preventive Medicine in Japan. Participants with high PSA (≥ 4.0 ng/ml) underwent further examination for prostate cancer. A subgroup analysis was conducted age group (<50 years, ≥ 50 years).

RESULTS

Mean age was 50 years. Mean PSA at baseline was 1.2 ng/ml. In over 50-year group, for those with initial PSA of <1.0, 1.0-1.9, 2.0-2.9, and 3.0-3.9 ng/ml at baseline, the 3-year cumulative incidence of prostate cancer was 0%, 0.1%, 0.3%, and 5.7%, respectively. No prostate cancer was identified in those <50 years, regardless of PSA level.

CONCLUSIONS

If PSA screening is recommended, males >50 years with PSA of 3.0-3.9 ng/ml at baseline should undergo rescreening at 2 years. For men with PSA <3.0 ng/ml, PSA rescreening at intervals of ≥ 3 years is appropriate. PSA screening may not be indicated in males of <50 years of age.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effectiveness of systemic corticosteroids in relieving symptoms of acute sinusitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) and the NHS Health Economics Database, MEDLINE (1966 to June week 2, 2011) and EMBASE (January 2009 to June 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of the trials and extracted data.

MAIN RESULTS

Four RCTs with a total of 1008 adult participants met our inclusion criteria. We judged studies to be of moderate methodological quality. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants received oral antibiotics and were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in three trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In all trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at Days 3 to 7, risk ratio (RR) 1.4, 95% CI 1.1 to 1.8; risk difference (RD) 20% (6% to 34%) and at Days 4 to 10 or 12, RR 1.3, 95% CI (1.0 to 1.7), RD 18% (3% to 33%). An analysis of the three trials with placebo as a control treatment showed similar results but with a lesser effect size: Days 3 to 6: RR 1.2, 95% CI (1.1 to 1.4), RD 12% (5% to 19%) and Days 4 to 10 or 12: RR 1.1, 95% CI (1.0 to 1.2), RD 10% (3% to 16%). Scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). We did not identify any data on the long-term effects of oral corticosteroids on this condition, such as effects on relapse or recurrence rates. Reported side effects of oral corticosteroids were limited and mild.

AUTHORS' CONCLUSIONS

Current evidence suggests that oral corticosteroids as an adjunctive therapy to oral antibiotics are effective for short-term relief of symptoms in acute sinusitis. However, data are limited and there is a significant risk of bias. High quality trials assessing the efficacy of systemic corticosteroids both as an adjuvant and a monotherapy in primary care patients with acute sinusitis should be initiated.