Cochrane Skin Group systematic reviews are more methodologically rigorous than other systematic reviews in dermatology

BACKGROUND

The Cochrane collaboration aims to produce high-quality systematic reviews. It is not known whether the methods used in producing Cochrane Skin Group (CSG) reviews result in higher quality reviews than other systematic reviews in dermatology.

OBJECTIVES

To determine how the methodological quality of dermatological CSG reviews published in The Cochrane Library and in peer-reviewed journals compare with non-Cochrane systematic reviews.

METHODS

Two blinded investigators independently assessed review quality using the 10-item Oxman and Guyatt scale.

RESULTS

Thirty-eight systematic reviews (17 Cochrane reviews published in The Cochrane Library, 11 Cochrane reviews published in peer-reviewed journals and 10 non-Cochrane reviews published in peer-reviewed journals) were examined. The Cochrane Library reviews included quality of life (11/17 vs. 1/10, P = 0.014) and adverse outcomes (14/17 vs. 2/10, P = 0.003) more often than non-Cochrane reviews published in peer-reviewed journals. Cochrane reviews published in both peer-reviewed journals and The Cochrane Library were more likely to include comprehensive search strategies (11/11 and 17/17 vs. 6/10, P-values = 0.04 and 0.01), take steps to minimize selection bias (11/11 and 16/17 vs. 3/10, P-values = 0.003 and 0.001) and appropriately assess the validity of all included trials (10/11 and 16/17 vs. 4/10, P-values = 0.04 and 0.007) than non-Cochrane reviews. Overall, Cochrane reviews published both in peer-reviewed journals and in The Cochrane Library were assigned higher quality scores by reviewers than non-Cochrane reviews (median = 6.0 and 6.5 vs. 4.5, P-values = 0.01 and 0.002).

CONCLUSIONS

The Cochrane Library systematic review methodology leads to higher quality reviews on dermatological topics.

Improving palliative care: A 2x2x2 factorial cluster randomized controlled trial of case conferencing and educational outreach visiting

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Background: Evidence-based palliative care service delivery models are needed. General practitioner (GP) and patient-centered case conferences may increase multidisciplinary interaction and enhance patient care. Educational outreach visiting in pain management may empower learners and improve care. Methods: Three interventions were tested against a routine care control in a 2×2×2 cluster factorial randomized controlled trial. Interventions were case conferencing, educational visiting for GPs, and educational visiting for patients. Subjects were adult patients referred to palliative care services in southern Adelaide, Australia, with any pain in the preceding 3 months. Participants were followed longitudinally until death. Main outcomes included performance status (Australian-modified Karnofsky Performance Status (AKPS)) and hospitalization rates. Longitudinal intention-to-treat analyses using cluster-specific methods were conducted. The sample goal was 460. Results: 461 participants were enrolled from 4/02–6/04. Mean age was 71 yrs, 50% were male, 91% had cancer. Mean and median survival was 146 and 87 days; median baseline AKPS was 60%. When participants had AKPS <70 (i.e. required a caregiver) at referral, those randomized to case conferencing or patient education had higher mean performance status than routine care (case conferencing: average daily AKPS, 54.9% vs 46.3%, p=0.0106; patient education: 54.7% vs 46.4%, p=0.0120). GP education did not improve performance status. Both case conferencing and patient education significantly decreased hospitalization rates compared to routine care (case conferencing: least-squares mean number of hospitalizations, 1.4 (standard error (SE) 0.1) vs 1.9 (SE 0.1), p=0.0002; patient education: 1.4 (SE 0.1) vs 1.8 (SE 0.1), p=0.0078). The addition of both interventions decreased hospitalizations to 1.2 (SE 0.1). Conclusion: At a time when declining function and higher healthcare utilization is the norm, palliative care that includes a case conference or patient educational visiting for pain leads to improved performance status and decreased hospitalizations. Patients with deteriorating performance status derive the greatest benefit.

No significant financial relationships to disclose.

Vascularity and expression of vascular endothelial growth factor in oral squamous cell carcinoma, resection margins, and nodal metastases

The role of vascularity as a predictor of the likelihood of lymph node metastases in oral cancer is not clear. To that end, the vascularity and expression of vascular endothelial growth factor (VEGF) was assessed at three specific regions: the tumour (inside and around the tumour); the resection margin; and the regional lymph nodes. Formalin-fixed paraffin-embedded specimens from 26 oral cancers (11 with no involved nodes and 15 with involved nodes) were stained immunohistochemically and examined. Staining for VEFG was significantly greater in the tumour than in the other sites. No significant differences were found in the intensity of staining in the primary tumour, resection margins, or nodes between cases in which the nodes were involved and in which they were not involved. We found no correlation between vascularity and VEGF staining, suggesting that VEGF is not the primary or only stimulator of angiogenesis in oral cancer. Greater understanding of the mechanisms of metastasis will lead to new treatments. The evidence that is accumulating for oral cancer suggests that such treatments may be better targeted at preventing lymphatic spread, rather than vascular spread.

The DNA sequence and biological annotation of human chromosome 1

The reference sequence for each human chromosome provides the framework for understanding genome function, variation and evolution. Here we report the finished sequence and biological annotation of human chromosome 1. Chromosome 1 is gene-dense, with 3,141 genes and 991 pseudogenes, and many coding sequences overlap. Rearrangements and mutations of chromosome 1 are prevalent in cancer and many other diseases. Patterns of sequence variation reveal signals of recent selection in specific genes that may contribute to human fitness, and also in regions where no function is evident. Fine-scale recombination occurs in hotspots of varying intensity along the sequence, and is enriched near genes. These and other studies of human biology and disease encoded within chromosome 1 are made possible with the highly accurate annotated sequence, as part of the completed set of chromosome sequences that comprise the reference human genome.

The costs of changing national policy: lessons from malaria treatment policy guidelines in Tanzania

OBJECTIVE

To document the cost incurred by the Tanzanian government by changing the policy on first-line treatment of malaria, from chloroquine to sulfadoxine-pyrimethamine.

METHODS

Costs were analysed from the perspective of the Ministry of Health and included all sources of funding. Costs external to the public health sector (e.g. private and community costs) were not included. The base case analysis adopted an incremental rather than a full cost approach, assuming that an organizational infrastructure was already in place. However, specific attention was paid to the burden placed on National Malaria Control Program staff. We also costed activities planned but not implemented to estimate the total expense for an 'ideal' process.

RESULTS

Total costs were Tsh 795 million (USD 813,743), with the largest proportion accounted for by training. Costs of the policy change process were equivalent to about 4% of annual government and donor expenditure on malaria and to about 1% of overall public expenditure on health. A number of planned activities were not implemented; including these would bring the total cost to Ts 880 million (USD 896,130).

CONCLUSION

On top of extra costs for the drugs themselves, a change in treatment policy requires time, resources and substantial management capacity at national and local level. A better understanding of these issues and the costs involved benefits countries planning and implementing policy change.

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries

OBJECTIVES

To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability.

SUBJECTS AND SETTING

Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury.

METHODS

Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)).

RESULTS

Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups.

CONCLUSIONS

The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

Mediastinitis and retropharyngeal abscess following delayed diagnosis of glass ingestion

Foreign body ingestion is a common occurrence in childhood. We report the outcome of an infant who swallowed a piece of glass. The absence of a foreign body on chest radiograph led to delayed diagnosis and then to the well documented complications of retropharyngeal abscess and mediastinitis. She was admitted to the paediatric intensive care unit a week after her initial presentation, subjected to multiple invasive and non-invasive procedures, and 6 weeks after her initial presentation to the accident and emergency department, was discharged back to her referring hospital having re-established oral feeds.

Massive retropharyngeal lymphadenopathy in an infant: an unusual presentation of infectious mononucleosis

Infectious mononucleosis causing upper airway obstruction due to tonsillar disease and associated lymphadenopathy in adolescents is well recognized. However, infection with Epstein-Barr virus (EBV) in a young child of six months is rare. The authors present such a case, with massive swelling of the retropharyngeal lymph nodes, that has not been published previously. The patient presented to this department with a short history of an upper respiratory tract infection and mild upper airway obstruction. On examination there was a massive enlargement of the retropharyngeal space with a compromised airway. This was confirmed on X-ray. She made an uneventful recovery following incision and drainage and a short period of endotracheal intubation. Because of the presence of retropharyngeal lymphoid tissue in infancy an alternative site of upper airway obstruction may occur here in this age group.

Genome wide significant linkage in schizophrenia conditioning on occurrence of depressive episodes

BACKGROUND

Schizophrenia shows substantial clinical heterogeneity. One common important clinical variable in presentation is the occurrence of episodes of major depression.

METHODS

We undertook analyses in an attempt to detect loci that influence susceptibility to, or modify the clinical expression of, schizophrenia according to the occurrence of episodes of major depression. We used a logistic regression framework in which lifetime presence/absence of major depression was entered as a covariate in the linkage analysis of our UK schizophrenia affected sibling pair series (168 affected sibling pairs typed for a 10 cM map of microsatellite markers).

RESULTS

Inclusion of presence/absence of depression as a covariate detected a genome wide significant linkage signal on chromosome 4q28.3 at 130.7 cM (LOD = 4.59; p = 0.038; increase in maximum LOD over univariate analysis (ILOD) = 3.62). Inclusion of the depression covariate also showed suggestive evidence of linkage on 20q11.21 (LOD = 4.10; expected to occur by chance 0.093 times per genome scan, ILOD = 2.83).

CONCLUSIONS

Our findings identify loci that may harbour genes that play a role in susceptibility to, or modify the risk of, episodes of major depression in people with schizophrenia.

A family based study of catechol-O-methyltransferase (COMT) and attention deficit hyperactivity disorder (ADHD)

Neurobiological studies have suggested that altered dopaminergic function may contribute to the etiology of attention deficit hyperactivity disorder (ADHD). The gene encoding catechol-O-methyltransferase (COMT) is an attractive candidate for ADHD susceptibility as it plays a major role in the degradation of dopamine. Moreover, a functional Val158Met polymorphism in COMT that alters the activity of the encoded protein has been strongly implicated in frontal lobe function, with the high activity Valine allele being associated with poorer performance, and ADHD is thought to involve fronto-striatal pathways. We have examined this functional variant for association with ADHD in a family based association sample comprising 279 probands and their parents. We have also examined two other markers in the COMT gene (rs737865, rs165599) which, together with the Val/Met variant, have recently been shown to be associated with altered COMT expression rather than enzyme activity. No evidence for association was observed with any single marker or haplotype in a sample of 279 affected children and their parents.

Multicenter linkage study of schizophrenia loci on chromosome 22q

The hypothesis of the existence of one or more schizophrenia susceptibility loci on chromosome 22q is supported by reports of genetic linkage and association, meta-analyses of linkage, and the observation of elevated risk for psychosis in people with velocardiofacial syndrome, caused by 22q11 microdeletions. We tested this hypothesis by evaluating 10 microsatellite markers spanning 22q in a multicenter sample of 779 pedigrees. We also incorporated age at onset and sex into the analysis as covariates. No significant evidence for linkage to schizophrenia or for linkage associated with earlier age at onset, gender, or heterogeneity across sites was observed. We interpret these findings to mean that the population-wide effects of putative 22q schizophrenia susceptibility loci are too weak to detect with linkage analysis even in large samples.

Identification in 2 Independent Samples of a Novel Schizophrenia RiskHaplotype of the Dystrobrevin Binding Protein Gene (DTNBP1)

CONTEXT

Recent research suggests that variation in the gene encoding dystrobrevin binding protein (DTNBP1) confers susceptibility to schizophrenia. Thus far, no specific risk haplotype has been identified in more than 1 study.

OBJECTIVES

To confirm DTNBP1 as a schizophrenia susceptibility gene, to identify and replicate specific risk and protective haplotypes, and to explore relationships between DTNBP1 and the phenotype.

DESIGN

Genetic association study based on mutation detection and case-control analysis.

SETTING

All subjects were unrelated and ascertained from general (secondary care) psychiatric inpatient and outpatient services.

PARTICIPANTS

The Cardiff, Wales, sample included 708 white subjects from the United Kingdom and Ireland (221 females) who met DSM-IV criteria for schizophrenia and were individually matched for age, sex, and ethnicity to 711 blood donor controls (233 females). Mean +/- SD age at first psychiatric contact for cases was 23.6 +/- 7.7 years; mean age at ascertainment was 41.8 +/- 13.5 years. The Dublin, Ireland, sample included 219 white subjects from the Republic of Ireland who met DSM-III-R criteria for schizophrenia or schizoaffective disorder and 231 controls. The mean age of the Irish cases was 46.0 +/- 8.5 years; mean age at first psychiatric contact was 25.2 +/- 12.4 years.

MAIN OUTCOME MEASURE

Evidence for association between the DTNBP1 locus and schizophrenia.

RESULTS

In the Cardiff sample, there was no evidence for association with previously implicated haplotypes but strong evidence for association with multiple novel haplotypes. Maximum evidence was found for a novel 3-marker haplotype (global P<.001), composed of 1 risk haplotype (P =.01) and 2 protective haplotypes, 1 common (P =.006) and 1 rare (P<.001). Specific risk and protective haplotypes were replicated in the Dublin sample (P =.02,.047, and.006, respectively). The only phenotypic variable associated with any haplotype was between the common protective haplotype and higher educational achievement (P =.02, corrected for multiple tests).

CONCLUSIONS

DTNBP1 is a susceptibility gene for schizophrenia. Specific risk and protective haplotypes were identified and replicated. Association with educational achievement may suggest protection mediated by IQ, although this needs to be confirmed in an independent data set.

Prognostic markers in node-negative breast cancer: A prospective study

BACKGROUND

Despite years of research, it is still unclear which women with node-negative (N-) breast cancer will need adjuvant chemotherapy and which women are being treated unnecessarily. Our goal was to determine which factors best predicted disease free survival (DFS) or cancer-specific overall survival (OS) and, therefore, select the correct patients for treatment. A total of 11 parameters were measured: estrogen receptor (ER), progesterone receptor (PR), age, race, ploidy status, %G0/G1 (% non-DNA synthesis), %S (% S-phase), cathepsin D status, size, stage, and histologic grade.

RESULTS

In this prospective study, we followed 556 N- patients diagnosed between 1991 and 1996. The tumors were 56% ER+, 51% PR+, 30% diploid, with a mean %S of 8.9%. The level of cathepsin D ranged from 0.50 to 155 pmol/mg of protein with a mean of 42.9 pmol/mg of protein. There were 87 recurrences (16%) and 72 cancer deaths (13%), with a median follow-up of 7.8 years. Ploidy status (p = 0.01), S-phase activity (p = 0.003), G1 phase activity (p = 0.02) and age (p = 0.01) were able to significantly predict DFS in a univariate manner. All of the measurable factors were significant or borderline significant in predicting OS in a univariate manner except for age, race, and ER status. In multivariate analysis with S-phase included, it was the only remaining factor in DFS and OS; with S-phase excluded, age and ploidy status remained as factors for DFS in stepwise regression, while PR, size, and cathepsin D were the remaining factors that predicted cancer-specific OS. The effect of adjuvant treatment on prognosis was also analyzed.

CONCLUSIONS

Both biochemical and clinical parameters have the potential to predict prognosis for N- breast cancer. In this large prospective clinical trial, with a median follow-up of 7.8 years, no individual marker adequately predicted the prognosis for an individual patient. %S activity was the best independent marker, but only 77% of the tumors provided this value. Subset analysis provided improved prognostication, but there were limits to its utility. These data represents a definitive study starting in 1991 and ending in 2002.

A systematic genomewide linkage study in 353 sib pairs with schizophrenia

We undertook a genomewide linkage study in a total of 353 affected sib pairs (ASPs) with schizophrenia. Our sample consisted of 179 ASPs from the United Kingdom, 134 from Sweden, and 40 from the United States. We typed 372 microsatellite markers at approximately 10-cM intervals. Our strongest finding was a LOD score of 3.87 on chromosome 10q25.3-q26.3, with positive results being contributed by all three samples and a LOD-1 interval of 15 cM. This finding achieved genomewide significance (P<.05), on the basis of simulation studies. We also found two regions, 17p11.2-q25.1 (maximum LOD score [MLS] = 3.35) and 22q11 (MLS = 2.29), in which the evidence for linkage was highly suggestive. Linkage to all of these regions has been supported by other studies. Moreover, we found strong evidence for linkage (genomewide P<.02) to 17p11.2-q25.1 in a single pedigree with schizophrenia. In our view, the evidence is now sufficiently compelling to undertake detailed mapping studies of these three regions.

Adolescence and other risk factors for Chlamydia trachomatis genitourinary infection in women in Melbourne, Australia

OBJECTIVE

To establish the prevalence of and risk factors for Chlamydia trachomatis infection to determine the role of universal versus targeted testing.

METHODS

A prospective study of 1107 women attending two sexual and reproductive health clinics in Melbourne, Australia, was carried out. A questionnaire was used to establish risk factors. Urine samples were tested for C. trachomatis by PCR. The main outcome measures were prevalence of and risk factors for C. trachomatis infection.

RESULTS

Of 1107 recruitable women, 851 (76.9%) consented and were successfully tested. C. trachomatis was detected in 18 (4.8% (95% CI 2.9 to 7.5)) of 373 women in the inner city and eight (1.7% (95% CI (0.7 to 3.3)) of 478 women in the suburban clinic. Of women under 25 years, 17 (6.2% (95% CI 3.7 to 9.8)) of 273 in the inner city in contrast with three (1.7% (95% CI 0.4 to 5.0)) of 174 in the suburban clinic were infected. In the inner city clinic, age under 25 years (OR 5.4 (95% CI 0.7 to 41.5)), vaginal discharge (OR 4.1 (95% CI 1.5 to 11.1)), and recent change of sexual partner (OR 4.6 (95% CI 1.6 to 12.9)) were associated with C. trachomatis. In contrast, in the suburban clinic, only vaginal discharge (OR 3.5 (95% CI 0.9 to 14.3)) and recent change of sexual partner (OR 3.4 (95% CI 0.8 to 15.7)) were identified as risk factors. Multivariate analysis showed that recent change of partner (OR 4.5 (95% CI 1.5 to 13.8)) was the most strongly associated independent risk factor for infection in the inner city clinic.

CONCLUSION

The high prevalence of C. trachomatis indicates that universal testing should be undertaken in the inner city clinic. Young age may not be a risk factor for C. trachomatis in more affluent populations with lower prevalence rates. No risk factors were identified with sufficient sensitivity and specificity to be useful for targeted testing. Prevalence and identifiable risk factors for C. trachomatis are not transferable between populations, even in the same city.

Characterisation, mutation detection, and association analysis of alternative promoters and 5' UTRs of the human dopamine D3 receptor gene in schizophrenia

The dopamine D(3) receptor gene (DRD3) is a candidate for a number of psychiatric conditions including schizophrenia, bipolar disorder and alcohol and drug abuse. Previous studies have reported associations between polymorphisms in DRD3 and these disorders, but these findings may have reflected linkage disequilibrium with pathogenic variants that are further upstream. We have isolated and sequenced approximately 9 kb of genomic sequence upstream of the human DRD3 translational start site. Using 5' RACE, we have identified within this region three additional exons and two putative promoter regions which show promoter activity in three different cell lines. A 5' UTR identified only in lymphoblasts is spread over three exons and is 353 bp long. A second 5' UTR, found in adult and fetal brain, lymphocytes, kidney and placenta is spread over two exons and is 516 bp long. A 260-bp sequence within this 9 kb corresponds to a previously reported EST, but corresponding mRNA could not be found in the tissues above. The EST, 5' UTRs and putative promoter regions have been analysed for polymorphisms, revealing 10 single nucleotide polymorphisms, seven of which were tested for association in a large sample of unrelated patients with schizophrenia and matched controls. No associations were observed with schizophrenia. In addition we failed to replicate previous findings of association with homozygosity of the Ser9Gly variant. The results from this study imply that neither the coding nor the regulatory region of DRD3 plays a major role in predisposition to schizophrenia.

Phytosterols reduce in vitro metastatic ability of MDA-MB-231 human breast cancer cells

Metastasis plays a major role in morbidity and mortality from breast cancer. Differences in the incidence and mortality of breast cancer between societies suggest that environmental factors such as diet may play a role in the disease. Previous work from this laboratory suggests that dietary phytosterols (PS) may offer protection from breast cancer by inhibiting growth of the tumor and its metastasis in severe combined immunodeficient mice. Because metastasis is a multistep process, the aim of the present study was to investigate the effect of PS on some steps of the metastatic process: tumor cell invasion, adhesion, and migration. In addition, cell growth and cell cycle progression were evaluated. MDA-MB-231 cells were supplemented with cholesterol, beta-sitosterol, and campesterol. Cells were treated for 3 days with 16 microM sterol that was loaded on 5 mM cyclodextrin. beta-Sitosterol inhibited tumor cell invasion through Matrigel and adhesion of cells to plates coated with collagen I, collagen IV, fibronectin, and laminin compared with cholesterol treatments and controls. Cholesterol treatment resulted in increased adhesion to laminin and collagen IV, two basement membrane (BM) components that are implicated in signaling tumor cell invasion in this cell line. Only cholesterol treatment increased cellular migration. beta-Sitosterol inhibited cell growth by 70% compared with controls and induced cell cycle arrest at the G2/M phase. It is concluded that, among PS, beta-sitosterol may offer protection from breast cancer metastasis by inhibiting cell invasion of the BM, which may be mediated by its ability to limit the adhesive interaction of the tumor cell and the BM.