A study to determine the minimum volume of blood necessary to be discarded from a central venous catheter before a valid sample is obtained in children with cancer

BACKGROUND

The objective of this study was to determine the minimum volume of blood that should be discarded from a range of different types of central venous catheter (CVC), such that the subsequent blood sample was not diluted or contaminated by the residual intra-luminal fluid.

PROCEDURE

Seventy children aged 1-19 years with central venous access inserted as part of their standard clinical treatment were recruited to this prospective study. Statistical comparison of the extent of variation in biochemical and haematological parameters observed between two blood samples taken following routine 5 ml discard blood volumes, as compared to the extent of variation between samples drawn following a 5 ml discard volume and <5 ml volumes, was carried out.

RESULTS

Data indicate that the measurement error in a clinical sample obtained following a 3 ml discard volume is no different to the measurement error obtained when using a standard 5 ml discard volume. Comparable results were obtained from patients with various different types of CVC or portacath access.

CONCLUSIONS

The withdrawal of a 3 ml discard volume is sufficient to ensure that the subsequent blood sample is not diluted or contaminated by residual intra-luminal fluid. This may have a significant clinical impact in paediatric oncology, where patients frequently require blood transfusions due to the haematological toxicities associated with chemotherapy. It is hoped that these results will impact on hospital policies concerning specified discard volumes taken from CVCs prior to the withdrawal of blood samples for research purposes and routine clinical analysis.

Measurement of television viewing in children and adolescents: a systematic review

The relationship between television (TV) viewing and overweight in children is likely to be influenced by the quality of measures used. We systematically reviewed studies related to overweight in children that had included a measure of TV exposure. Literature searches were conducted in MedLINE, PsychInfo, SportDiscus and ISIWeb of Science. Methods of assessing TV viewing were evaluated, including the type of measure, the administration procedure and reported psychometric properties. The majority of studies assessed TV viewing using self-report surveys and very few studies used direct observation. The validity or reliability of measures was often not examined. The majority of tools that were evaluated were compared with another self-report measure or an objective measure of physical activity. TV viewing measures should be selected that are specific to the research question, the study design, as well as methodological feasibility. However, it is recommended that measures of TV viewing be used only if they have psychometric data to support their validity and reliability. Selecting measures that are valid and reliable enables us to examine with greater accuracy the influence of TV viewing on childhood overweight, as well as the efficacy of interventions designed to reduce TV viewing in children.

Local corticosteroid injection for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown.

OBJECTIVES

To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006).

SELECTION CRITERIA

Randomized or quasi-randomized studies.

DATA COLLECTION AND ANALYSIS

Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated.

MAIN RESULTS

We included 12 studies with altogether 671 participants. Two high quality randomized controlled trials with altogether 141 participants demonstrated clinical improvement of carpal tunnel syndrome at one month or less following local corticosteroid compared to placebo injection (relative risk 2.58 (95% confidence intervals 1.72 to 3.87)). One trial compared local corticosteroid injection to oral corticosteroid and at 12 weeks after treatment there was significantly more improvement in the injection group (mean difference -7.10 (95% confidence intervals -11.68 to -2.52)). In one trial, the rate of improvement after one month was greater after local than systemic corticosteroid injection (relative risk 3.17 (95% confidence intervals 1.02 to 9.87)). In one trial, symptoms did not improve significantly more in the injection group at eight weeks after injection compared to treatment with anti-inflammatory medication and splinting (mean difference 0.10 (95% confidence intervals -0.33 to 0.53)). Two injections versus one injection of local corticosteroid did not provide further clinical improvement, mean difference -3.80 (95% CI -9.27 to 1.67).

AUTHORS' CONCLUSIONS

Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Significant symptom relief beyond one month has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement than oral corticosteroid for up to three months. Local corticosteroid injection does not significantly improve clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium-Neon laser treatment after six months. Two local corticosteroid injections do not provide significant added clinical benefit compared to one injection.

Outcomes of intervention programs using flatscreen virtual reality

Virtual reality (VR) has the potential to offer experiences which are engaging and rewarding. In VR, the focus is shifted from the person's efforts in producing a movement or completing a task to that of interaction with the virtual environment. We have found that participants place value and meaning on and enjoy the activities programmed. Virtual reality interventions have been shown to improve cognitive function and concentration through an individual's interaction with a pleasant activity. Importantly, the enjoyment experienced while working with VR may increase the level of participation. In addition to generating realistic situations for testing, intervention and collection of data, the provision of immediate and positive feedback through VR has been shown to increase self esteem and empowerment. We will report outcomes from several intervention and feasibility trials using a flat screen virtual reality system with survivors of traumatic brain injury, community living older adults and children with spastic cerebral palsy. Gross motor movements were elicited through various game-like VR applications without the need for head-mounted displays or other peripherals. The impact of VR exercise participation ranged from improvements in clinical measures of functional balance and mobility, time on task, as well as participant and care provider perceptions of enjoyment, independence and confidence. Although still preliminary, our data suggest that simple applications of virtual reality have significant impacts on physical and psychosocial variables. Possibilities for and benefits of home and community-based access to virtual reality based programs will be explored.

Experiences with dose finding in patients in early drug development: the use of biomarkers in early decision making

With the increasing cost and complexity of drug development, biomarkers will play an increasing role in the early phases. Biomarkers can be classified into target, mechanistic, or outcome with varying degrees of linkage to disease or treatment effect. They can be used to determine proof of concept by characterising the efficacy or safety profiles, or determining differentiation from any competitor drugs. PK/PD modelling of biomarker data for novel and marketed compounds can be used to predict outpatient dose response. Subsequent simulations may replace or reduce the size and cost of larger phase 2b outpatient studies. Two examples of biomarkers and PK/PD modelling used to characterise dose response are presented. Penile plethysmography (RigiScan Plus) in male erectile dysfunction and phenylephrine challenge urethral pressure in benign prostatic hyperplasia are used to reduce time and cost to reach major exploratory development decision points in these indications.

Chronic toxicity of sediment-associated linear alkylbenzene sulphonates (LAS) to freshwater benthic organisms

The toxicity of linear alkylbenzene sulphonates (LAS), to freshwater benthic organisms was assessed during exposure to spiked sediment. Lethal and sub-lethal end-points were monitored for two organisms (oligochaete Lumbriculus variegatus and nematode Caenorhabditis elegans). Results demonstrated relatively low toxicity (LOECs>100 mg/kg dry weight). No observed effect concentrations (NOECs) of 81 mg/kg dw (Lumbriculus) and 100 mg/kg dw (Caenorhabditis) were determined. For the oligochaete, no specific endpoint was particularly sensitive to LAS. For the nematode, egg production was the most sensitive endpoint. Significant degradation was measured over the 28-day duration of the Lumbriculus study, equating to a half-life of 20 days in sediment.

Quality control of the total lymphocyte count parameter obtained from routine haematology analyzers, and its relevance in HIV management

Lylmphocyte subsets/CD4 T Helper cell enumeration in HIV care and treatment in resource constrained settings can be difficult to ascertain as a result of the lack of the necessary instrumentation, capacity and infrastructure. However. it is imperative to gain such information for patient monitoring in HIV. The Total Lymphocyte Count (TLC) is useful as a surrogate marker for CD4 count as recommended by the World Health Organisation (WHO) and to calculate CD4% for pacdiatric use. This study therefore sets out to determine and compare the accuracy of the total lymphocyte counts obtained from three haematology analysers designated A. B and C. that are in regular use for routine haemnatological parameters at the main referral hospital in Barbados. West Indies. The TLC of 263 HIV treatment naive individuals attending the HIV Reference Unit in Barbados were enumnerated on the three haematology analysers. The lymphosumn (Sum of lymphocyte subsets: T-helper cell. T-cytotoxic cells. B lymphocytes and Natural killer cells) should be equal to the TLC. and is derived by immunophenotypic analysis on a 4-colour flowcytometer. Machine C had the highest positive correlation between the TLC and the lymphosumn with and R' of 0.9031 compared to machine A with an R values of 0.7119 and Machine B with R(2) values of 0.637. These results show that there can be dramatic inaccuracies when using routine haematology analysers for both routine use. as a surrogate marker of CD4 or for derivation of CD4% in HIV management. It further demonstrates that all haematology analyzers require some form of Quality control. The possible lack of accuracy of the TLC by haematology analysers should be taken into consideration when following the recommendations of the WHO in resource poor settings or using it as a denominator for calculating CD4%.

A secure web-based approach for accessing transitional health information for people with traumatic brain injury

A web-based transitional health record was created to provide regional healthcare professionals with ubiquitous access to information on people with brain injuries as they move through the healthcare system. Participants included public, private, and community healthcare organizations/providers in Eastern Ontario (Canada). One hundred and nineteen service providers and 39 brain injury survivors registered over 6 months. Fifty-eight percent received English and 42% received bilingual services (English-French). Public health providers contacted the regional service coordinator more than private providers (52% urban centres, 26% rural service providers, and 22% both areas). Thirty-five percent of contacts were for technical difficulties, 32% registration inquiries, 21% forms and processes, 6% resources, and 6% education. Seventeen technical enquiries required action by technical support personnel: 41% digital certificates, 29% web forms, and 12% log-in. This web-based approach to clinical information sharing provided access to relevant data as clients moved through or re-entered the health system. Improvements include automated digital certificate management, institutional health records system integration, and more referral tracking tools. More sensitive test data could be accessed on-line with increasing consumer/clinician confidence. In addition to a strong technical infrastructure, human resource issues are a major information security component and require continuing attention to ensure a viable on-line information environment.

Detecting altered postural control after cerebral concussion in athletes with normal postural stability

OBJECTIVE

To determine if approximate entropy (ApEn), a regularity statistic from non-linear dynamics, could detect changes in postural control during quiet standing in athletes with normal postural stability after cerebral concussion.

METHODS

The study was a retrospective, case series analysis of centre of pressure (COP) data collected during the Sensory Organization Test (SOT) from NCAA Division I (USA) athletes prior to and within 48 h after injury. Subjects were 21 male and six female athletes from a variety of sports who sustained a cerebral concussion between 1997 and 2003. After injury, athletes displayed normal postural stability equivalent to preseason levels. For comparison, COP data also were collected from 15 male and 15 female healthy non-athletes on two occasions. ApEn values were calculated for COP anterior-posterior (AP) and medial-lateral (ML) time series.

RESULTS

Compared to healthy subjects, COP oscillations among athletes generally became more regular (lower ApEn value) after injury despite the absence of postural instability. For AP time series, declines in ApEn values were much larger in SOT conditions 1 and 2 (approximately three times as large as the standard error of the mean) than for all other conditions. For ML time series, ApEn values declined after injury in all sensory conditions (F(1,55) = 6.36, p = 0.02).

CONCLUSIONS

Athletes who demonstrated normal postural stability after concussion nonetheless displayed subtle changes in postural control. Changes in ApEn may have represented a clinically abnormal finding. ApEn analysis of COP oscillations may be a valuable supplement to existing concussion assessment protocols for athletes.

Incidence of allergy and allergy symptoms among workers exposed to laboratory animals

BACKGROUND AND AIMS

Few studies have described relations between exposure to laboratory animals and the incidence of laboratory animal allergy (LAA). Studies that have found exposure-response relations have been cross sectional in design or have focused on exposure to rats and mice. This study used longitudinal data collected over a 12 year period to describe the relations between indices of exposure to laboratory animals and the development of LAA and LAA symptoms.

METHODS

Data were obtained from questionnaires and serological laboratory results from a dynamic cohort of workers exposed to a variety of laboratory animals in a pharmaceutical manufacturing company. Poisson regression was used to model the incidence rate ratios of species specific and general LAA and LAA symptoms at different levels of exposure.

RESULTS

The 12 year incidence rates of LAA symptoms and LAA for all workers were 2.26 (95% CI 1.61 to 2.91) and 1.32 (95% CI 0.76 to 1.87) per 100 person-years, respectively. Higher rate ratios were seen with increasing reported hours of exposure to tasks that required working with animal cages or with many animals at one time. The most common symptoms were related to rhinitis rather than to asthma.

CONCLUSIONS

This study suggests that the risk of LAA increases with duration of exposure to animals and work in animal related tasks. Incidence might be reduced by limiting hours per week of exposure to laboratory animals.

CD56(+dim) and CD56(+bright) cell activation and apoptosis in hepatitis C virus infection

CD3- CD56(+dim) natural killer (NK) cells, which are cytotoxic against virally infected cells, may be important in hepatitis C virus (HCV)-infected patients who are successfully treated with pegylated interferon (PEG-IFN)-alpha. We used flow cytometry to enumerate activated (CD69+) and apoptotic (annexin-V+) dim (CD3- CD56(+dim)) and bright (CD3- CD56(+bright)) NK cells obtained from HCV-infected patients before treatment (n=16) and healthy controls (n=15) in the absence and presence of pegylated interferon (PEG-IFN)-alpha-2b. A subset of HCV-infected patients, subsequently treated with PEG-IFN-alpha-2b in vivo, was determined to have a sustained virological response (SVR, n=6) or to not respond (NR) to treatment (n=5). In the absence of IFN, activated dim (CD3- CD56(+dim) CD69+) NK cells were significantly decreased (P=0.04) while activated apoptotic dim (CD3- CD56(+dim)CD69+ annexin-V+) NK cells tended to be increased (P=0.07) in SVR patients compared with NR patients. Activated bright (CD3-CD56(+bright)CD69+) and activated apoptotic bright (CD3- CD56(+bright)CD69+ annexin-V+) NK cells were significantly correlated (P=0.02 and P=0.01, respectively) with increasing hepatic inflammation. These findings suggest that in the absence of PEG-IFN, activated dim (CD3- CD56(+dim)CD69+) NK cell turnover may be enhanced in SVR compared with NR patients and that activated bright (CD3- CD56(+bright)CD69+) NK cells may play a role in liver inflammation.

Antinuclear antibodies (ANA) in chronic hepatitis C virus infection: correlates of positivity and clinical relevance

We examined correlates of antinuclear antibody (ANA) positivity (ANA+) in individuals with chronic hepatitis C virus (HCV) infection and the effect of positivity on clinical outcome of HCV. Pretreatment sera from 645 patients from three centres in Sweden (n = 225), the UK (n = 207) and Italy (n = 213) were evaluated by indirect immunofluorescence on Hep-2 cells for ANA pattern and titre by a single laboratory. Liver biopsies were all scored by one pathologist. A total of 258 patients were subsequently treated with interferon monotherapy. There was a significant difference in the prevalence of ANA (1:40) by geographic location: Lund 4.4%, London 8.7%, Padova 10.3% [odds ratio (OR) = 0.66; 95% CI: 0.46-0.94; P = 0.023]. Duration of HCV infection, age at infection, current age, route of infection, viral genotype, alcohol consumption, fibrosis stage and inflammatory score were not correlated with ANA+ or ANA pattern. Female gender was correlated with ANA+ and this association persisted in multivariable analyses (OR = 3.0; P = 0.002). Increased plasma cells were observed in the liver biopsies of ANA-positive individuals compared with ANA-negative individuals, while a trend towards decreased lymphoid aggregates was observed [hazard ratio (HR) = 9.0, P = 0.037; HR = 0.291, P = 0.118, respectively]. No correlations were observed between ANA positivity and nonresponse to therapy (OR = 1.4; P = 0.513), although ANA+ was correlated with faster rates of liver fibrosis, this was not statistically significant (OR = 1.8; P = 0.1452). Low titre ANA+ should not be a contraindication for interferon treatment. Our observation of increased plasma cells in ANA+ biopsies might suggest B-cell polyclonal activity with a secondary clinical manifestation of increased serum immunoglobulins.

Introduction of IFCC reference method for calibration of HbA: implications for clinical care

Abstract HbA(1c) is recommended for monitoring glycaemic control and quantifying the risk of complications in patients with diabetes. National guidelines for treatment of patients with diabetes in UK specify that HbA(1c) measurements should be Diabetes Control and Complications Trial (DCCT)-aligned i.e. comparable to the DCCT and UK Prospective Diabetes Study (UKPDS). The IFCC reference method for HbA(1c) will be introduced in Europe in December 2003 for calibration of all laboratory and POCT (point of care testing) methods for HbA(1c) following the recent EC "In Vitro Diagnostic" (IVD) directive. This reference method involves measurement of HbA(1c) and HbA(0) by electron-spray ionisation-mass spectrometry or capillary electrophoresis with the reference range approximately 2% HbA(1c) lower than the corresponding range from the DCCT. However, this EC IVD directive will not change reporting of DCCT-aligned HbA(1c) in the UK. Professionals involved in the care of patients with diabetes in the UK met with Dr Sue Roberts in London in July 2003. It was decided that in the UK DCCT-aligned HbA(1c) will continue to be reported from December 2003 for patient care and that laboratories currently reporting non-aligned DCCT HbA(1c) should change to reporting DCCT-aligned results as soon as possible. It was considered important for diabetes care in the UK that the reporting of HbA(1c) should not fragment. The UK HbA(1c) Standardization Committee was set up to hold "a watching brief " on HbA(1c) especially with relation to reporting of HbA(1c) in other countries.

Experimental production of gastric dilation and its association with osmoregulatory stress and biogenic amines in chinook salmon, Oncorhynchus tshawytscha (Walbaum)

Chinook salmon smolt in fresh water fed a commercial diet known to produce minimal gastric dilation and air sacculitis (GDAS) were randomly assigned to four experimental tanks with flow-through sea water. All four groups were acclimatized to sea water for 3 weeks and fed a diet of minced fresh seafood. After 3 weeks the groups were fed either; seafood as before, a different commercial pelleted diet associated with the development of GDAS on farms, or either diet supplemented with 500 mg L(-1) putrescine, 300 mg L(-1) cadaverine and 250 mg L(-1) tyramine. Gastric dilation was produced in fish fed the commercial diet for 1 month but not by feeding a diet of minced seafood. The addition of putrescine, cadaverine and tyramine to either diet had no significant effect on the development of gastric dilation. Fish fed the commercial diet had significantly (P < 0.0001) wider weight-adjusted stomach widths, less prominent longitudinal stomach folds (P < 0.0001) and lower (P < 0.0001) stomach-width ratios than fish fed the fresh seafood diet. There was no significant difference in serum osmolality or sodium concentration between fish from groups with or without gastric dilation or fed biogenic amines.

Sporadic neoplasms of farmed chinook salmon, Oncorhynchus tshawytscha (Walbaum), from New Zealand

Eight separate neoplasms with five distinct morphologies are described in the present report. The spontaneous neoplasms were identified in farmed chinook salmon, Oncorhynchus tshawytscha (Walbaum), during processing. The masses were examined histologically and were classified as teratoma, rhabdosarcoma, biliary and renal cystadenomas, renal carcinoma and three leiomyomas. This represents one neoplasm detected for every 125000 fish processed during the sampling period.

Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome

BACKGROUND

Non-surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown.

OBJECTIVES

To evaluate the effectiveness of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions in improving clinical outcome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non-surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non-surgical treatments.

MAIN RESULTS

Twenty-one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) -1.07; 95% confidence interval (CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to -0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21) which was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti-inflammatory drugs) versus placebo. Compared to placebo, pooled data for two-week oral steroid treatment demonstrated a significant improvement in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also showed improvement after four weeks (WMD -10.8; 95% CI -15.26 to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control.

REVIEWER'S CONCLUSIONS

Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non-surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit.

The effect of alcohol consumption on cost of care in severe psychotic illness: a report from the UK700 study

OBJECTIVE

Alcohol misuse in psychotic patients is common and leads to poor treatment outcome. This study examines the relationship between alcohol consumption and cost of care in patients with a severe psychotic illness.

METHOD

Patient care was evaluated over 2 years for 708 patients. Patient reported alcohol consumption was evaluated at initial interview. The outcome measure was cost of care over 2 years.

RESULTS

There was no difference in mean cost of care between non-drinkers, moderate and heavy drinkers. Increased alcohol consumption (measured as a continuous variable, adjusted for baseline characteristics) was associated with lower cost of care.

CONCLUSION

Heavier alcohol consumers did not incur more treatment costs and may, indeed, cost less than other patients. This may reflect higher levels of drinking being associated with better overall functioning, poorer engagement with services or exclusion from services.

The study of CTLA-4 and vitamin D receptor polymorphisms in the Romanian type 1 diabetes population

Several studies suggested that part of the genetic susceptibility for Type 1 diabetes (T1DM) is encoded by some polymorphisms of CTLA-4 gene (2q33) and of Vitamin D Receptor gene (VDR; 12q12-14). Our aim was to assess their contribution to T1DM genetic susceptibility in the Romanian population. We typed CTLA-4 49 A/G and VDR FokI (F/f), ApaI (A/a) and TaqI (T/t) polymorphisms by Sequence Specific Primer PCR (SSP-PCR) in 204 Romanian diabetic families (756 individuals: 212 T1DM probands and 544 unaffected parents and siblings). We studied alleles transmission using the Transmission Disequilibrium Test (TDT). We found an increased transmission of CTLA-4 49G allele to diabetics (54.8%, p=0.11). The transmission of F (56.1%, p=0.063), a (55.7%, p=0.061) and T (51.8%, p=0.37) alleles of VDR gene to diabetics was increased but did not reach statistical significance. In conclusion we found the same increased transmission of CTLA-4 49 G allele to diabetics as previously reported. VDR FoqI F allele seems to be predisposing while TaqI T allele seems to be protective.

Local corticosteroid injection for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the level of the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness and duration of benefit of local corticosteroid injection for Carpal tunnel syndrome remain unknown.

OBJECTIVES

To evaluate the effectiveness of local steroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions in improving clinical outcome and to determine the length of symptom relief.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group register (searched June 2002), MEDLINE (searched January 1966 to May 2002), EMBASE (searched January 1980 to May 2002)and CINAHL(searched January 1982 to May 2002).

SELECTION CRITERIA

We included randomized or quasi-randomized studies of participants with carpal tunnel syndrome treated with local corticosteroid injection. The primary outcome measure was clinical improvement.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected the trials to be included rated for their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated.

MAIN RESULTS

We identified nine randomized controlled trials. Four were excluded. One trial demonstrated clinical improvement of carpal tunnel syndrome at one month following local corticosteroid compared to placebo injection (Relative risk 3.83 (95% confidence intervals 1.82 to 8.05)). One trial compared local corticosteroid injection to oral steroid and at three months after treatment there was a significant improvement in the injection group (mean difference -7.00 (95% confidence intervals -11.58 to -2.42)). In one trial the rate of improvement after one month was greater after local than systemic corticosteroid injection (Relative risk 3.17(95% confidence intervals 1.02 to 9.87)). In one trial symptoms did not improve significantly for the injection group at eight weeks after injection compared to treatment with anti-inflammatory medication and splinting (mean difference 0.10 (95% confidence intervals -0.33 to 0.53)). Although local steroid injection did provide benefit compared to Helium-Neon Laser treatment at two weeks after onset of treatment (Relative risk 0.27 (95% CI 0.09 to 0.83), this effect did not hold at six months follow-up (Relative risk 0.76 (95% confidence intervals 0.48 to 1.21).

REVIEWER'S CONCLUSIONS

Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Symptom relief beyond one month compared to placebo has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement compared to oral steroid up to three months after treatment. Local corticosteroid injection does not provide improved clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium -Neon laser treatment after six months.

Low frequency of HLA DRB1*03 - DQB1*02 and DQB1*0302 haplotypes in Romania is consistent with the country's low incidence of Type I diabetes

AIMS/HYPOTHESIS

Our study aimed to determine the association of HLA class II HLA-DQB1 alleles with Type I (insulin-dependent) diabetes mellitus and the frequencies of these alleles in the Romanian population, which has one of the lowest incidences of Type I diabetes in children aged 0-14 years in Europe at 3-4 cases per 100,000 person-years.

METHODS

We used the sequence specific primer-polymerase chain reaction (PCR-SSP) technique to type HLA-DQB1 alleles, the HLA-DRB1alleles DRB1*03 and one single nucleotide polymorphism (SNP) in the insulin gene (INS). We studied 204 Type I diabetic Romanian families, 196 of which were simplex with 70.3 % of subjects diagnosed under 14 years of age. Data was analysed using a modified version of the Transmission Disequilibrium Test, the Transmission Disequilibrium Test itself, and the affected family-based control method.

RESULTS

We found, as expected, the strong positive DQB1*02-DRB1*03 and DQB1*0302, and negative DQB1*0602, HLA class II allele associations with Type I diabetes in these Romanian families. However, using the affected family-based control method, we found relatively low population frequencies of DQB1*02-DRB1*03 and DQB1*0302 alleles in Romania (15.8%) compared with Sardinia (31.3%), a high incidence European region (35 cases per 100,000 person-years in children aged 0-14years). The INS locus had a strong effect in this data set with 80.5 % transmission of the susceptible INS allele from parents to affected siblings (relative risk = 4.1).

CONCLUSION/INTERPRETATION

Part of the explanation for the low incidence of Type I diabetes in Romania could be the lower frequency of the DRB1*03 DQB1*02 and DQBI*0302 susceptibility haplotypes in this country.