Transcutaneous electrical nerve stimulation for knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a disease that affects synovial joints, which mainly causes degeneration and destruction of hyaline cartilage. To date, no curative treatment for OA exists. The primary goals for OA therapy are to relieve pain, maintain or improve functional status, and minimize deformity. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality in physiotherapy that is commonly used to control both acute and chronic pain arising from several conditions. A number of trials evaluating the efficacy of TENS in OA have been published.

OBJECTIVES

To assess the effectiveness of TENS in the treatment of knee OA. The primary outcomes of interest were those described by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) 3, which included pain relief, functional status, patient global assessment, and change in joint imaging for studies of one year or longer. The secondary objective was to determine the most effective mode of TENS application in pain control.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, HEALTHSTAR, PEDro, Current Contents and the Cochrane Controlled Trial Register using the Cochrane Musculoskeletal Group search strategy for trials up to and including December 1999. We also hand-searched reference lists and consulted content experts.

SELECTION CRITERIA

Two independent reviewers selected the trials that met predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted the data using standardized forms and assessed the quality of randomization, blinding and dropouts. A third reviewer was consulted to resolve any differences. For dichotomous outcomes, relative risks (RR) were calculated. For continuous data, weighted mean differences (WMD) or standardized mean difference (SMD) of the change from baseline were calculated. A fixed effects model was used unless heterogeneity of the populations existed. In this case, a random effects model was used.

MAIN RESULTS

Seven trials were eligible to be included in this review. Six used TENS as the active treatment while one study used acupuncture-like TENS (AL-TENS). A number of 148 and 146 patients were involved in the active TENS treatment and placebo, respectively. Three studies were cross-over studies and the others were parallel group, randomized controlled trials (RCTs). Median methodological quality of these studies was two. Pain relief from active TENS and AL-TENS treatment was significantly better than placebo treatment. Knee stiffness also improved significantly in active treatment group compared to placebo. Different modes of TENS setting (High Rate and Strong Burst Mode TENS) demonstrated a significant benefit in pain relief of the knee OA over placebo. Subgroup analyses showed a heterogeneity in the studies with methodological quality of three or more and those with repeated TENS applications.

REVIEWER'S CONCLUSIONS

TENS and AL-TENS are shown to be effective in pain control over placebo in this review. Heterogeneity of the included studies was observed, which might be due to the different study designs and outcomes used. More well designed studies with a standardized protocol and adequate number of participants are needed to conclude the effectiveness of TENS in the treatment of OA of the knee.

Thermotherapy for treating rheumatoid arthritis

BACKGROUND

Heat and cold therapy are often used as adjuncts in the treatment of rheumatoid arthritis by rehabilitation specialists.

OBJECTIVES

To evaluate the effects of heat and cold on objective and subjective measures of disease activity in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched Medline, Embase, PEDro, Current Contents, Sports Discus and CINAHL up to June 2000. The Cochrane Field of Rehabilitation and related therapies and the Cochrane Musculoskeletal Review Group were also contacted for a search of their specialized registers. Handsearching was conducted on all retrieved articles for additional articles.

SELECTION CRITERIA

Randomized or controlled clinical trials of ice or heat compared to placebo or active interventions in patients with rheumatoid arthritis and case-control and cohort studies were eligible. No language restrictions were applied. Abstracts were accepted.

DATA COLLECTION AND ANALYSIS

Two independent reviewers identified potential articles from the literature search. These reviewers extracted data using pre-defined extraction forms. Consensus was reached on all data extraction. Quality was assessed by two reviewers using a 5 point scale that measured the quality of randomization, double-blinding and description of withdrawals.

MAIN RESULTS

Three studies (79 subjects) met the inclusion criteria. There was no effect on objective measures of disease activity (including inflammation, pain and x-ray measured joint destruction) of either ice versus control or heat versus control. Patients reported that they preferred heat therapy to no therapy (94% like heat therapy better than no therapy). There was no difference in patient preference for heat or ice. No harmful effects of ice or heat were reported.

REVIEWER'S CONCLUSIONS

Since patients enjoy thermotherapy, and there are no harmful effects, thermotherapy should be recommended as a therapy which can be applied at home as needed to relieve pain. There is no need for further research on the effects of heat or cold for RA.

Appointment of a Resuscitation Training Officer is associated with improved survival from in-hospital ventricular fibrillation/ventricular tachycardia cardiac arrest

OBJECTIVE

To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospital ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.

DESIGN

A 22-month prospective study.

SETTING

A 1100-bed teaching hospital.

SUBJECTS

All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests.

INTERVENTIONS

Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitation training for all staff.

MAIN OUTCOME

Survival to discharge.

RESULT

Improvement in survival to discharge of 20-75% (P<0.03, Spearman Rank Correlation test).

CONCLUSION

Appointment of a Resuscitation Training Officer is associated with improved survival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest.

Heart failure due to ischaemic heart disease: epidemiology, pathophysiology and progression

Ischaemic heart disease is the most common underlying cause of heart failure in industrialised countries. Its manifestations are protean with myocardial infarction being only one important facet. The prognosis of patients with heart failure due to ischaemic heart disease also appears to be worse than that associated with many other aetiologies. The presence of ischaemic heart disease may influence both the efficacy and choice of treatment. Agents such as digoxin and amlodipine appear less effective in patients with ischaemic heart disease while ACE inhibitors and beta-blockers appear as or more effective in patients with ischaemic heart disease. Many have expressed an opinion about how coronary disease should be managed in the patient with heart failure supported by little or no evidence. There are major theoretical and practical concerns about the use of anti-coagulant, anti-platelet and statin therapy in patients with heart failure as well as major theoretical benefits. Only randomised controlled trials will resolve these issues. The same may be said of revascularisation. Fortunately trials addressing all these areas are under way. This should put the management of coronary disease in patients with heart failure on a firm evidence-based footing.

Management of hypothermias in adults

Hypothermia has a high mortality. Mortality will depend on duration and depth of cooling. Matching rewarming to these variables may improve survival.

Responsiveness of endpoints in osteoporosis clinical trials--an update

As an update of our earlier paper, published as part of the Outcome Measures in Rheumatology Clinical Trials (OMERACT 3) proceedings in 1996, we surveyed the types of outcomes incorporated in recent clinical trials. A literature search was conducted on MEDLINE and Current Contents, from January 1996 to March 1998, using the search strategy recommended by the Cochrane Collaboration for the identification of randomized controlled trials (RCT). Two independent reviewers selected trials according to inclusion criteria. The same reviewers extracted data on clinical and radiographic fractures, pain, quality of life, and bone mineral density (BMD). Seventy-four RCT conducted on bone loss in postmenopausal women were identified. Most trials incorporated biochemical markers and BMD as outcome measures. Fewer trials included vertebral fractures, pain, height, and quality of life. The responsiveness is presented in terms of the sample size needed per group to show a statistically significant difference. The most responsive outcomes were pain, BMD, and biochemical markers. The number needed to treat to prevent one vertebral fracture ranged from 13 to 54, depending on the intervention and population. Investigators should examine the characteristics of the patient population and the nature of the intervention in determining the sample size required to demonstrate a significant effect. The selection of endpoints should be based on their responsiveness, feasibility, and the importance of using standardized outcomes. Standardized outcomes greatly facilitate the synthesis of available information into systematic reviews by groups such as the Cochrane Collaboration.

Beta-blockers for chronic heart failure: from prejudice to enlightenment

Experience accumulated from several large trials strongly suggest that beta-blockers should be used for the management of congestive heart failure (CHF). Beta-blockade should be added to conventional therapy such as diuretics, ACE inhibitors, and digoxin, as this was the approach used in the major trials. It is appropriate to treat patients with mild, moderate and, when stable, severe CHF. The benefits obtained include improvements in left ventricular function, reductions in symptoms and morbidity, improvement of quality of life, and delay of clinical progression, reflected by a reduced need for hospitalization and a reduction in mortality. Beta-blockers are much better tolerated, when used appropriately in selected patients, than was previously supposed.

Antimicrobial resistance in the intensive care unit: impact of new patterns

The effects of resistance are being observed on an increasing scale in the intensive care unit (ICU). Multi-resistant organisms are diminishing our ability to treat and control the spread of infection. Strategies for the control of resistant organisms in the ICU must be based on the underlying pathophysiology of resistance mechanisms. Resistance is also influenced by the setting in which health care is provided. In the United States (US), changes in the health care delivery system have had a dramatic impact on the number and type of ICU patients. Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology) is a co-operative project to measure antibiotic resistance and antibiotic use. Results show a relative increase in the number of ICU beds in US hospitals. They also indicate a significant stepwise decrease in the percentage of resistant organisms isolated from ICU patients, non-ICU inpatients, and outpatients. These results suggest that resources allocated to control of antimicrobial resistance should continue to be focused on the hospital and particularly the ICU. Study findings also indicate that antimicrobial use and resistance are usually, but not always, linked. This means that strategies for dealing with resistance must address several additional factors including infection control practices, community burden of resistance, and possibly others. Thus national or regional guidelines for preventing resistance will have to be modified to take into account local care patterns, problems and resources. When dealing with resistance in the ICU, 'one size will not fit all'.

Staff perceptions of substance use among acute psychiatry inpatients

This paper reports on a small-scale study undertaken in two inner city acute psychiatric wards to identify the proportion of patients known to use drugs or alcohol and the perceptions of staff regarding these patients. Data collection involved a retrospective audit of patient notes and the administration of a questionnaire to nursing staff. The findings were broadly consistent with other research studies. Over half of the patient sample was reported to use illicit drugs or alcohol and in one third of cases this use was thought to have contributed to their current admission. Questionnaire results indicated that staff felt ill-equipped to offer an adequate response although all respondents welcomed opportunities to develop their knowledge and skills. The findings are discussed in light of the existing literature, and some tentative conclusions are drawn concerning the development and provision of effective integrated services for individuals with psychiatric and psychoactive substance use disorders.

A vertical curriculum to teach the knowledge, skills, and attitudes of medical informatics

It is becoming increasingly apparent that medical schools must begin teaching the knowledge, skills and attitudes of information literacy and applied medical informatics as core competencies in undergraduate medical education. The University of Vermont College of Medicine recognized that these core competencies were lacking in its curriculum, and in 1992 it implemented a four year, integrated program to give students the information habits essential to twenty-first century practice. The first graduates of the program are now in residencies and feedback has enabled the College to refine the program to better meet the informatics education needs of the next generation of physicians. The result of these efforts is the Vertical Curriculum in Information Literacy and Applied Medical Informatics; its process of development, the product of the process, and its outcomes are discussed.

Correlation of the ratio of CD4+/CD8+ cells in lymph node fine needle aspiration biopsies with HIV clinical status. A preliminary study

OBJECTIVE

To test the hypothesis that lymph node (LN) fine needle aspiration biopsy (FNAB) may provide reliable measures of human immunodeficiency virus (HIV) disease status.

STUDY DESIGN

HIV+ participants in this study had persistent generalized lymphadenopathy without clinical evidence of lymphoma or nodal infections due to organisms other than HIV. Seven males and five females ranging in age from 23 to 55 and at HIV Centers for Disease Control (CDC) stages A2-C3 were enrolled in this study. From each participant, LN and blood samples were submitted for cytologic examination and flow cytometric analysis of lymphocyte subsets. Flow cytometry measures included T, B, CD4+, CD8+ and natural killer (NK) cells. The percentages of T, B and NK cells in LN and blood samples were different and reflected the expected distribution of these cell types in the respective tissues.

RESULTS

The percentages of CD4+ and CD8+ cells in blood and LN were different, but this variation was not statistically significant. In contrast, the ratio of CD4+/CD8+ cells in LN and blood was different and statistically significant (P < .001) for patients in CDC categories A2-B2 but not different for categories B3-C3. More important, there was a significant (r = .76) correlation between the ratio of CD4+/CD8+ cells in LN with CDC stage.

CONCLUSION

FNAB, in combination with flow cytometry, may prove to be an important tool in HIV clinical staging. However, further assessment, including clinical follow-up and participation of additional patients, is necessary and currently under way.

Resuscitation. IV: Advanced paediatric life support

Adults and children have cardiac arrests for very different reasons. The commonest reason for an adult cardiac arrest is a primary arrhythmia in association with ischaemic heart disease, i.e. ventricular fibrillation. Children have cardiac arrests because of respiratory failure, hypovolaemia (due to trauma and dehydration) and sepsis.

Resuscitation III: advanced trauma life support

Trauma is the leading cause of death in people less than 40 years old (Central Statistics Office, 1994). Patients who have sustained major trauma will often have multiple injuries. The key to treating these patients is an organized and systematic method of examination and treatment to ensure that injuries are not missed and left untreated.

Resuscitation. II: Advanced cardiac life support

Advanced cardiac life support is the definitive sequence of initial treatment for the victim of a cardiac arrest. Advanced cardiac life support forms a large part of cardiopulmonary resuscitation, which also includes basic life support and post-resuscitation intensive care.

Resuscitation. 1: Basic life support

Basic life support (BLS) is a method of sustaining vital functions in a person who has collapsed and is unconscious, frequently with a cardiac arrest but sometimes with respiratory arrest, choking or other cause. BLS is a vital link in the 'chain of survival' for these critically ill people.

Adult respiratory distress syndrome: a systemic overview of incidence and risk factors

OBJECTIVE

To determine the published incidence of adult respiratory distress syndrome (ARDS) as well as the clinical evidence supporting a casual association between ARDS and its major risk factors.

DATA SOURCES

The National Library of Medicine MEDLINE database and the bibliographies of selected articles.

STUDY SELECTION

Clinical studies were selected from the English literature, if they pertained to either the incidence of ARDS or its association with one or more commonly identified risk factors.

DATA EXTRACTION

All relevant studies identified by the search were evaluated for strength of design, and risk factors were scored according to established criteria for the strength of causation.

DATA SYNTHESIS

A total of 83 articles were considered relevant: six of incidence and 77 on risk factors. Only 49% of the 83 articles provided a definition of ARDS; a definition of risk factors was given in 64%, and 23% had no definition for either ARDS or risk factors. The published, population-based incidence of ARDS ranges from 1.5 to 5.3/10(5) population/yr. The strongest clinical evidence supporting a cause-effect relationship was identified for sepsis, aspiration, trauma, and multiple transfusions. The weakest clinical evidence was identified for disseminated intravascular coagulation. The following study types were represented by the 77 articles on risk factors: observational case-series (56%); cohorts (23%); case-controls (12%); nonrandomized clinical trials (5%); and randomized clinical trials (3%). Only a single study reported an odds ratio.

CONCLUSIONS

The significant variation in the incidence of ARDS is attributed to differences in the type and strength of study designs, as well as definitions or ARDS. While a substantial body of evidence exists concerning a casual role of ARDS risk factors, such as sepsis, aspiration, and trauma, > 60% of clinical studies employed weak designs. The lack of reproducible definitions for ARDS or its potential risk factors in 49% of studies raises concerns about the validity of the conclusions of these studies regarding the association between ARDS and the supposed risk factors.

Graphomotor perseveration and wandering in Alzheimer's disease

Perseveration, spatial orientation, and attention/concentration were assessed in 15 patients with a probable diagnosis of senile dementia of the Alzheimer's type. Subjects were divided into two groups, wanderers and nonwanderers, based on caregiver ratings using a modified version of the Caregiver Checklist. Graphic productions of wanderers on the Bender Visual Motor Gestalt Test and Clock Drawing Test displayed greater total perseveration and more recurrent and continuous perseverations than those of nonwanderers. Spatial orientation and attention/concentration were similar between groups. These preliminary results suggest that graphomotor perseverations exhibited during the mild to moderate stages may serve as a marker for wandering in Alzheimer's disease.

Pseudomonas aeruginosa infection in very low birth weight infants: a case-control study

The perinatal histories and hospital courses of all neonates born at Grady Memorial Hospital who developed Pseudomonas aeruginosa sepsis or meningitis in the 5-year period 1989-1993 were reviewed. In addition a case-control study was performed to evaluate selected risk factors for this infection. Twenty-one patients had one or more blood cultures positive for P. aeruginosa. An additional patient had P. aeruginosa meningitis without bacteremia. All infections occurred after 5 days of age. The overall incidence of P. aeruginosa infection was 0.7/1000 live births. All cases occurred in infants < 1500 g at birth, for a birth weight-specific rate of 19.5/1000 livebirths in this weight class. Clinical manifestations of disease did not distinguish P. aeruginosa from other causes of fulminant neonatal sepsis. Fifty percent of cases died. Mortality was inversely related to postnatal age at diagnosis. The 22 cases were compared with 44 controls matched for birth weight, gestational age, sex, duration of hospital stay and admission date. Cases were more likely than controls to have a history of feeding intolerance, interrupted enteral intake and prolonged parenteral hyperalimentation. Case infants received intravenous antibiotics for a significantly longer period of time than did controls. There was an association between P. aeruginosa sepsis and necrotizing enterocolitis (36% cases vs. 7% of controls had prior or concurrent necrotizing enterocolitis, P < 0.01). In summary P. aeruginosa sepsis is primarily a late onset nosocomial infection in very low birth weight infants. The case fatality rate of 50% in this series emphasizes its continued importance.

Climatic Warming and the Decline of Zooplankton in the California Current

Since 1951, the biomass of macrozooplankton in waters off southern California has decreased by 80 percent. During the same period, the surface layer warmed-by more than 1.5 degrees C in some places-and the temperature difference across the thermocline increased. Increased stratification resulted in less lifting of the thermocline by wind-driven upwelling. A shallower source of upwelled waters provided less inorganic nutrient for new biological production and hence supported a smaller zooplankton population. Continued warming could lead to further decline of zooplankton.

Networking a need: a cost-effective approach to statewide health information delivery

VTMEDNET is the health information network for the state of Vermont. In response to a needs assessment of rural health care providers, it supports e-mail, access to knowledge-bases, and the ability to request library services for health care providers across the state, regardless of their location or affiliation. For Fletcher Allen Health Care affiliates, it also supports access to in-patient hospital records. Two thirds of the state's physicians are using the network as well as many other health care providers, and, with minimal cost, it has begun to meet its goal of improving health care delivery to many of Vermont's citizens.

Effect of hemorrhagic hypotension on extracellular level of dopamine, cortical oxygen pressure and blood flow in brain of newborn piglets

The present study describes the relationships between extracellular striatal dopamine, cortical oxygen pressure and blood flow in brain of newborn piglets during hemorrhagic hypotension. Cerebral oxygen pressure was measured optically by the oxygen dependent quenching of phosphorescence; extracellular dopamine by in vivo microdialysis; striatal blood flow was monitored by a laser Doppler. Following a 2 h stabilization period after implanting the microdialysis and laser Doppler probes in the striatum, the mean arterial blood pressure (MABP) was decreased in stepwise manner from 87 +/- 4 Torr (control) to 35 +/- 5 Torr, during 63 min. The whole blood was then reinfused and measurements were continued for 45 min. Statistically significant decrease in blood flow, 10%, was observed when arterial blood pressure decreased to about 53 Torr. With further decrease blood pressure to 35 Torr, blood flow decreased to about 35% of control (P < 0.01). Cortical oxygen pressure decreased almost proportional to decrease in blood pressure. The progressive decrease in MABP from 87 +/- 4 Torr to 65 +/- 6, 52 +/- 7, and 35 +/- 5 Torr resulted in cortical oxygen pressure decreasing from 45 +/- 4 Torr to 33 +/- 3 Torr (P < 0.05), 24 +/- 4 Torr (P < 0.01) and 13 +/- 3 Torr (P < 0.01). The levels of extracellular dopamine in the striatum increased with decreasing cortical oxygen pressure. As cortical oxygen decreased, the extracellular dopamine increased to 230%, 420% and 3200% of control, respectively. Our results show that in mild hypotension total blood flow is well maintained but oxygen pressure in the microvasculature decreases, possibly due to heterogeneity in the regulatory mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)