The Author Truncation "et al." in Article References: An Anachronism That Needs to Change

Background: Valuable research requires contribution from many experts; however, the "et al." truncation often keeps all individuals from being acknowledged. The adoption of a new citation rule (list all authors up to 30, followed by et al.) would allow more authors to be acknowledged. The purpose of this study was to (1) explore the citation styles of the top 10 Plastic Surgery, Surgery, and Medical journals and (2) compare the number of extra pages required, and the number of additional authors acknowledged when the "new rule" is implemented. Methods: The top 10 journals in Plastic Surgery, Surgery, and Medicine were identified. The citation styles used in each of the journals were reviewed and the reference list from a recently published article was extracted. The original reference list was used to create an Extended Reference List using the new rule. Results: Most journals implemented "et al." when seven or more authors were listed. Ten articles required additional pages to accommodate the Extended Reference List. When the "et al." truncation was introduced after 30 authors, there was an almost 100% chance of all authors being included. The adoption of this rule rarely resulted in the need for additional pages, especially within Plastic Surgery. Conclusions: In a time of electronic publishing, where constraints such as article and journal page length should not be important factors, all authors should be recognized. The use of the "et al." truncation should be discouraged by all individuals involved in the production and publication of research. Scenario You are asked by the Editor-in-Chief of your specialty's journal to review an article in your area of expertise. You gladly accept the task. One of the questions you are required to answer in your review is whether the authors of the submitted manuscript have missed any important articles in their references. As you are the recognized expert in this field, you glance at the references to see if a key article you published 3 years earlier has been included. The first author of that article was a junior resident in your service and the research was done under your supervision. To their credit, the authors included the said article, but you are dismayed that the reference does not include your name. It includes only the names of the first three authors, all junior residents in your service. Your name, and the names of many others, are lost in the et al. truncation.

Telehealth coaching to improve self-management for secondary prevention after stroke: A randomized controlled trial of Stroke Coach

BACKGROUND

Stroke Coach is a lifestyle coaching telehealth program to improve self-management of stroke risk factors.

AIMS

To examine the efficacy of Stroke Coach on lifestyle behavior and risk factor control among community-living stroke survivors within one-year post stroke.

METHODS

Participants were randomized to Stroke Coach or an attention control Memory Training group. Lifestyle behavior was measured using the Health Promoting Lifestyle Profile II. Secondary outcomes included specific behavioral and cardiometabolic risk factors, health-related quality of life (HRQoL), cognitive status, and depressive symptoms. Measurements were taken at baseline, post-intervention (6 months), and retention (12 month). Linear mixed-effects models were used to test the study hypotheses (p < 0.05). All analyses were intention-to-treat.

RESULTS

The mean age of the Stroke Coach (n = 64) and Memory Training (n = 62) groups was 67.2 and 69.1 years, respectively. The majority of participants (n = 100) had mild stroke (modified Rankin Scale = 1 or 2), were active, with controlled blood pressure (mean = 129/79 mmHg) at baseline. At post-intervention, there were no significant differences in lifestyle (b = -2.87; 95%CI - 8.03 to 2.29; p = 0.28). Glucose control, as measured by HbA1c (b = 0.17; 95%CI 0.17 to 0.32; p = 0.03), and HRQoL, measured using SF-36 Physical Component Summary (b = -3.05; 95%CI -5.88 to -0.21; p = 0.04), were significantly improved in Stroke Coach compared to Memory Training, and the improvements were maintained at retention.

CONCLUSION

Stroke Coach did not improve lifestyle behavior; however, there were improvements to HbA1c and HRQoL among community-living stroke survivors with mild stroke-related disability. (ClinicalTrials.gov identifier: NCT02207023).

Alignment differs between patellofemoral osteoarthritis cases and matched controls: An upright 3D MRI study

Patellofemoral (PF) osteoarthritis (OA) is a prevalent and clinically important knee OA subgroup. Malalignment may be an important risk factor for PF OA. However, little is known about alignment in PF OA, particularly in an upright, weightbearing environment. Using a vertically-oriented open-bore MR scanner, we evaluated 3D knee alignment in 15 PF OA cases and 15 individually matched asymptomatic controls. We imaged one knee per participant while they stood two-legged at four flexion angles (0°, 15°, 30°, 45°), and also while they stood one-legged at 30° knee flexion. We calculated 3D patellofemoral and tibiofemoral alignment. Using mixed effects models, four of the five patellofemoral measures differed by group. For key measures, PF OA patellae were 6.6° [95%CI 5.0, 8.2] more laterally tilted, 2.4 mm [1.3, 3.5] more laterally translated, and at least 3.7 mm [0.2, 7.2] more proximally translated compared to controls (more with knees flexed). Alignment did not differ between two-legged stance and one-legged stance in either group. Statement of Clinical Significance: Our study demonstrated significant and clinically relevant differences in alignment between PF OA cases and controls in upright standing and squatting positions. Our findings were similar to those in previous studies of PF OA using traditional MR scanners in supine positions, supporting the clinical usefulness of existing methods aimed at identifying individuals who may benefit from interventions designed to correct malalignment. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. 9999:1-9, 2019.

A Systematic Review and Meta-Analysis of Subsequent Malignant Neoplasm Risk After Radioactive Iodine Treatment of Thyroid Cancer

Background: The potential risk of subsequent malignant neoplasms (SMNs) after radioactive iodine (RAI) treatment of thyroid cancer (TC) is an important concern. Methods: A systematic review was updated comparing the risk of SMNs in TC patients treated with RAI to TC patients without RAI. Six electronic databases were searched (up to March, 2018), supplemented with a hand search. Two reviewers independently screened citations, reviewed full-text papers, and critically appraised/abstracted data. Random-effects meta-analyses were conducted using crude data and data statistically adjusted for confounders. The outcomes were any SMN and specific SMNs for which sufficient data were available. Results: In total, 3506 unique electronic search citations and 93 full-text papers were examined, including 17 studies (3 systematic reviews and 14 original studies). Published knowledge syntheses were limited by inclusion of small numbers of studies, with two systematic reviews suggesting an increased risk of any SMN and one meta-analysis suggesting a reduced risk of breast SMN after RAI treatment. In a meta-analysis of crude data, the risk ratio of any SMN in RAI-treated TC patients was 0.98 ([confidence interval (CI) 0.76-1.27]; n = 10 studies of 65,539 individuals, heterogeneity Q = 64.26, degrees of freedom [df] = 9, p < 0.001, I² = 85.99). The pooled risk ratio for any SMN, adjusted for confounders, was 1.16 ([CI 0.97-1.39]; n = 6 studies, data from at least 11,241 TC patients, Q = 10.86, df = 5, p = 0.054, I² = 53.96). In secondary analyses examining specific SMNs, although relatively rare, the risk of subsequent leukemia was increased, but the risk of multiple myeloma was reduced in RAI-treated TC patients. There was no significant increased relative risk of breast cancer, salivary cancer, or combined hematologic malignancies according to RAI treatment status. Conclusions: The body of evidence on whether ¹³¹I treatment of thyroid cancer is associated with the primary outcome of any SMN is highly heterogeneous and complex. More research examining the long-term risk of specific SMNs after ¹³¹I treatment is needed.

Prospective surveillance and targeted physiotherapy for arm morbidity after breast cancer surgery: a pilot randomized controlled trial

OBJECTIVE

To evaluate prospective surveillance and targeted physiotherapy (PSTP) compared to education (EDU) on the prevalence of arm morbidity and describe the associated program cost.

DESIGN

Pilot randomized single-blinded controlled trial.

SETTING

Urban with assessments and treatment delivered in hospitals.

PARTICIPANTS

Women scheduled for breast cancer surgery.

INTERVENTIONS

Participants were randomly assigned (1:1) to PSTP ( n = 21) or EDU ( n = 20) and assessed presurgery and 12 months postsurgery. All participants received usual care, namely, preoperative education and provision of an education booklet with postsurgical exercises. The PSTP group was monitored for arm morbidity every three months and referred for physiotherapy if arm morbidity was identified. The EDU group received three education sessions on nutrition, stress and fatigue management.

MAIN OUTCOME MEASURES

Arm morbidity was based on changes in the surgical arm(s) from presurgery in four domains: (1) shoulder range of motion, (2) strength, (3) volume, and (4) upper body function. Complex arm morbidity indicated ≥2 domains impaired. Second, the cost of the PSTP program was described.

RESULTS

At 12 months, 18 (49%) participants (10 PSTP and 8 EDU) had arm morbidity, with EDU participants presenting more complex arm morbidity compared to PSTP participants. PSTP participants attended 4.4 of 5 assessments with 90% retention. The PSTP program cost was $150 covered by the Health Care Provider and the Patient Out-of-Pocket Travel cost was CAN$40.

CONCLUSION

Our results suggest that PSTP is feasible among women with breast cancer for early identification of arm morbidity. A larger study is needed to determine the cost and effectiveness benefits.

Support service utilization and out-of-pocket payments for health services in a population-based sample of adults with neurological conditions

Background

Social support can help to deal with the consequences of neurological conditions and promote functional independence and quality of life. Our aim was to evaluate the impact of neurological conditions on the use of support and health-care services in a population-based sample of community-dwelling adults with neurological conditions.

Methods

Data were from the Survey of Living with Neurological Conditions in Canada, which was derived from a representative sample of household residents. Formal and informal support received and out-of-pocket payments were assessed by personal interviews. Logistic regression was used to explore the association between support service utilization and six common neurological conditions (Stroke, Parkinson's disease, Alzheimer's disease/dementias, traumatic brain injury, spinal cord injury and multiple sclerosis) with stroke as the reference category.

Results

The sample contained 2,410 respondents and equate to an estimated 459,770 when sample weights were used. A larger proportion of people within each of the neurological conditions received informal support than formal support (at least twice as much). Samples with the non-stroke conditions were more likely to receive formal assistance for personal (odds ratios 2.7 to 5.6; P < 0.05) and medical (odds ratios 2.4 to 4.4; P < 0.05) care compared to the stroke group. Also, the non-stroke conditions were more likely to receive informal assistance (odds ratios 2.7 to 17.9; P < 0.05) and less likely to make out-of-pocket payments for rehabilitation therapy (odds ratios 0.2 to 0.3; P < 0.05) than the stroke group. The Alzheimer’s disease/dementia group had the highest proportion who received formal and informal support services.

Conclusions

Our findings suggest that Canadians with neurological conditions receive more informal assistance than formal assistance. Furthermore, it appears that stroke survivors receive less support services, while those with Alzheimer’s disease/dementia receive the most compared to other adult neurological conditions. Such data can help inform the development of support services in the community.

A telehealth intervention to promote healthy lifestyles after stroke: The Stroke Coach protocol

Rationale Recurrent stroke is prevalent and associated with high mortality rates, disability, and social and economic costs. Adequate management of risk factors may reduce recurrent stroke; however, many stroke survivors have poor control of risk factors. We have developed a theoretically sound and evidence-based lifestyle modification program called the Stroke Coach, a telephone-based self-management program to improve control of risk factors. Hypothesis Individuals who participate in Stroke Coach will achieve more lifestyle improvements than individuals in an attention controlled Memory Training Program. Design In this single blind randomized controlled trial, 126 community-living stroke survivors will be randomized to Stroke Coach or the attention control group. Participants randomized to the six-month Stroke Coach will receive seven telephone lifestyle coaching sessions, self-management education and practice, and a self-monitoring kit, comprised of a health report card, with blood pressure and activity monitors. Study Outcomes The primary outcome will be measured using the Health Promoting Lifestyle Profile II. Secondary outcomes include behavioral and physiological risk factors, quality of life, cognitive status, health and social service use. Measurements will be taken at baseline, immediately after the intervention and six-month post-intervention. Summary The results of this trial will add to our understanding of the use of self-management to improve control of risk factors, and may facilitate the development of a larger trial evaluating the effect of Stroke Coach on endpoints such as recurrent stroke or cardiac events as the primary outcome.

Users' guide to the surgical literature: how to assess a noninferiority trial

SUMMARY

A well-planned randomized controlled trial (RCT) is the most optimal study design to determine if a novel surgical intervention is any different than a prevailing one. Traditionally, when we want to show that a new surgical intervention is superior to a standard one, we analyze data from an RCT to see if the null hypothesis of "no difference" can be rejected (i.e., the 2 surgical interventions have the same effect). A noninferiority RCT design seeks to determine whether a new intervention is not worse than a prevailing (standard) one within an acceptable margin of risk or benefit, referred to as the "noninferiority margin." In the last decade, we have observed an increase in the publication of noninferiority RCTs. This article explores this type of study design and discusses the tools that can be used to appraise such a study.

Feasibility of a Systematic, Comprehensive, One-to-One Training (SCOOT) program for new scooter users: study protocol for a randomized control trial

Background

Mobility scooters can facilitate community participation among individuals with mobility limitations. However, accidents are a serious concern with scooter use. Scooter training has been recommended to improve safety, but there are currently few validated programs available. Therefore, we developed a Systematic, Comprehensive, One-to-One Training (SCOOT) program for scooter users. We will conduct a study to evaluate the outcomes produced by the provision SCOOT.

Methods

This feasibility study will use a mixed-methods, rater-blinded, randomized control trial, with a two-step wedge design. The study has two arms: an immediate intervention group, which will receive the intervention directly after baseline assessments, and a delayed intervention group, which will receive the intervention after a 6-week period. Forty participants, who will be stratified based on whether or not participants have previously held a driver’s license, will be randomly assigned to each arm. The intervention for this study consists of 6 weeks of one-to-one scooter training by an experienced occupational therapist, who will provide training once or twice per week over the 6 weeks. The primary outcome measure is subjective scooter skills, measured using the Wheelchair Skills Test for scooters. Secondary outcomes include objective scooter skills, confidence, mobility, and satisfaction with selected participation activities. Descriptive measures include cognitive status, functional status, hearing, vision, physical accessibility of the home and community, and visual attention and task switching. Qualitative interviews will be conducted with the first ten willing participants from each group to learn about their scooter use and experiences with SCOOT.

Discussion

The results of this study will inform a larger randomized control trial. If the intervention is proven to be effective in this larger study, it may have important implications for policy and practice.

Trial registration

ClinicalTrials.gov identifier: NCT02696213. Registered on 23 February 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1963-y) contains supplementary material, which is available to authorized users.

Measurement properties of the Wheelchair Skills Test for scooters among experienced users

PURPOSE

To investigate the score distribution, reliability, and validity of the objective Wheelchair Skills Test (WST) for scooter users.

METHOD

A study using a test-retest design was conducted with 20 people who had mobility limitations that prevented them from ambulating more than one city block without a mobility aid, and who had owned a scooter for ≥3 months. Objective scooter skills, confidence, and physical accessibility were measured at both time points, while anxiety, depression, visual attention and task switching, functional independence, and visual acuity were measured only at baseline.

RESULTS

The mean total WST scores at Time 1 and Time 2 were 86.3% and 87.5%. The WST ICC was 0.889. The WST had a SEM of 2.50 and a Cronbach's alpha of 0.74. The total WST scores were significantly correlated with total subjective WST-Q scores (r = 0.547, p = 0.013), scooter confidence (r = 0.466, p = 0.038), and were affected by gender (p = 0.005).

CONCLUSION

The WST for scooters has good test-retest reliability and generally varies as anticipated with other measures. Although further study is needed, the WST for scooters appears to have promise for use in research and clinical practice. Implications for Rehabilitation It is important to understand the measurement properties of the tools we use in rehabilitation so the results can be interpreted correctly. As scooter use increases, better measurement of skills is required.

Users' guide to the surgical literature: how to assess an article about harm in surgery

CLINICALSCENARIO

You are a new plastic surgeon in the community and you are referred a patient interested in breast reconstruction. The patient is a 35-year-old female school teacher who had a bilateral prophylactic mastectomy 2 years earlier, as she was a BRCA gene carrier. Since she is of a petite build with very little subcutaneous tissue or extra skin in the lower abdomen, you decide that she is not a suitable candidate for an abdomen-based autologous tissue reconstruction. You recommend the technique of tissue expansion and silicone gel implants. She is concerned, however, about the possibility of anaplastic large cell lymphoma (ALCL) developing in her breasts. She read in a magazine recently that ALCL, an unusual form of breast cancer, has been occurring in patients who have breast implants. She is very concerned that she might be at risk and asks for your opinion as to whether she should proceed with the procedure or not.

Feasibility and preliminary efficacy of a physical activity counseling intervention using Fitbit in people with knee osteoarthritis: the TRACK-OA study protocol

Background

Physical activity (PA) reduces pain and improves functioning in people with knee osteoarthritis (OA), but few people with the condition meet recommended PA guidelines. Successful intervention strategies to increase PA include goal setting, action planning, self-monitoring, and follow-up feedback from a healthcare professional. Recently developed consumer wearable activity trackers allow users to set activity goals, self-monitor daily goal-progress, and provide feedback on goal attainment. It is hypothesized that a multi-component physiotherapist-led intervention that includes a short (40-min) education module, guided goal-setting and action planning, the use of a wristband activity tracker, and weekly follow-up phone calls will lead to increased PA outcomes.

Methods/design

Thirty-six participants will be recruited from the community for a two-group pilot randomized controlled trial with a stepped-wedge design using an intention-to-treat analysis. Computer-generated block randomization will be performed using varying block sizes and a 1:1 allocation ratio. The 4-week intervention will be delivered immediately (immediate-intervention group) or after a 5-week delay (delayed-intervention group). Outcome measures of pain and disability (Knee Injury and OA Outcome Score), disease self-management ability (Partners in Health Scale), and objective bouted moderate-to-vigorous PA and sedentary time (BodyMedia SenseWear Mini Armband) will be collected at baseline (week 0) and two follow-ups (weeks 5 and 10), for a total study duration of 11 weeks. Feasibility data relating to process, resource, management, and scientific elements of the trial will be collected. Outcome measure and feasibility data will be summarized, and an estimate of intervention efficacy will be obtained by regression model with planned comparisons. The trial began recruiting in February 2015. To date, 34 subjects have been recruited.

Discussion

This study will evaluate the feasibility and preliminary efficacy of a novel intervention to promote PA in people living with knee OA. The results will provide valuable information to inform a larger randomized trial to assess intervention effectiveness.

Trial registration

ClinicalTrials.gov Identifier: NCT02313506 (registration date 8 December 2014). First participant randomized 20 February 2015.

Coronary artery calcification, cardiovascular events, and death: a prospective cohort study of incident patients on hemodialysis

Background

Coronary calcification in patients with end-stage renal disease (ESRD) is associated with an increased risk of cardiovascular outcomes and death from all causes. Previous evidence has been limited by short follow-up periods and inclusion of a heterogeneous cluster of events in the primary analyses.

Objective

To describe coronary calcification in patients incident to ESRD, and to identify whether calcification predicts vascular events or death.

Design

Prospective substudy of an inception cohort.

Setting

Tertiary care haemodialysis centre in Ontario (St Joseph’s Healthcare Hamilton).

Participants

Patients starting haemodialysis who were new to ESRD.

Measurements

At baseline, clinical characterization and spiral computed tomography (CT) to score coronary calcification by the Agatston-Janowitz 130 scoring method. A primary outcome composite of adjudicated stroke, myocardial infarction, or death.

Methods

We followed patients prospectively to identify the relationship between cardiac calcification and subsequent stroke, myocardial infarction, or death, using Cox regression.

Results

We recruited 248 patients in 3 centres to our main study, which required only biochemical markers. Of these 164 were at St Joseph’s healthcare, and eligible to participate in the substudy; of these, 51 completed CT scanning (31 %). Median follow up was 26 months (Q₁, Q₃: 14, 34). The primary outcome occurred in 16 patients; 11 in the group above the median and 5 in the group below (p = 0.086). There were 26 primary outcomes in 16 patients; 20 (77 %) events in the group above the coronary calcification median and 6 (23 %) in the group below (p = 0.006). There were 10 deaths; 8 in the group above the median compared with 2 in the group below (p = 0.04). The hazard ratios for coronary calcification above, compared with below the median, for the primary outcome composite were 2.5 (95 % CI 0.87, 7.3; p = 0.09) and 1.7 (95 % CI 0.55, 5.4; p = 0.4), unadjusted and adjusted for age, respectively. For death, the hazard ratios were 4.6 (95 % CI 0.98, 21.96; p = 0.054) and 2.4 (95 % CI 0.45, 12.97; p = 0.3) respectively.

Limitations

We were limited by a small sample size and a small number of events.

Conclusions

Respondent burden is high for additional testing around the initiation of dialysis. High coronary calcification in patients new to ESRD has a tendency to predict cardiovascular outcomes and death, though effects are attenuated when adjusted for age.

A cosmesis outcome substudy in a prospective, randomized trial comparing radioguided seed localization with standard wire localization for nonpalpable, invasive, and in situ breast carcinomas

BACKGROUND

The primary study objective was to compare the cosmetic result of radioguided seed localization (RSL) with wire localization (WL).

METHODS

A subgroup of patients enrolled in a multicentered, randomized trial comparing WL with RSL participated. Frontal photographs were taken 1 and 3 years postsurgery. The European Organization for Research and Treatment of Cancer Cosmetic Rating System was used to evaluate cosmesis outcomes by the patient and a panel of 5 raters.

RESULTS

The study enrolled 73 patients (WL, n = 38; RSL, n = 35). Most patients rated their overall cosmesis as "excellent" or "good" (76% WL, 80% RSL). Patient and panel ratings on all cosmetic outcomes were similar between groups. Multivariable regression for overall cosmesis found larger specimen volume and reoperation to be predictors of worse ratings.

CONCLUSIONS

All cosmetic outcomes assessed were similar after WL and RSL. The comparable outcomes may reflect similar reoperation rates and volumes of excision between groups.

Osteoarthritis incidence and trends in administrative health records from British Columbia, Canada

OBJECTIVE

To calculate the incidence rates of osteoarthritis (OA) and to describe the changes in incidence using 18 years of administrative health records.

METHODS

We analyzed visits to health professionals and hospital admission records in a random sample (n = 640,000) from British Columbia, Canada, from 1991/1992 through 2008/2009. OA was defined in 2 ways: (1) at least 1 physician diagnosis or 1 hospital admission; and (2) at least 2 physician diagnoses in 2 years or 1 hospital admission. Crude and age-standardized rates were calculated, and the annual relative changes were estimated from the Poisson regression models.

RESULTS

In 2008/2009, the overall crude incidence rate (95% CI) of OA using definition 1 was 14.6 (14.0-14.8); [12.5 (12.0-13.0) among men and 16.3 (15.8-16.8) among women] per 1000 person-years. The rates were lower by about 44% under definition 2. For the period 2000/2001-2008/2009, crude incidence rates based on definition 1 varied from 11.8 to 14.2 per 1000 person-years for men, and from 15.7 to 18.5 for women. Annually, on average, crude rates rose by about 2.5-3.3% for both men and women. The age-adjusted rates increased by 0.6-0.8% among men and showed no trend among women.

CONCLUSION

Our study generated updated incidence rates of administrative OA for the Province of British Columbia. Physician-diagnosed overall incidence rates of OA varied with the case definitions used; however, trends were similar in both case definitions. Age-adjusted rates among men increased slightly during the period 2000/2001-2008/2009. These findings have implications for projecting future prevalence and costs of OA.

Risk of cardiovascular disease in patients with osteoarthritis: a prospective longitudinal study

OBJECTIVE

To determine the risk of cardiovascular disease (CVD) among osteoarthritis (OA) patients using population-based administrative data from British Columbia, Canada.

METHODS

The medical history of a random sample of 600,000 individuals from 1991-2009 was analyzed. A total of 12,745 OA cases and up to 3 non-OA individuals matched by age, sex, and year of diagnosis were followed for CVD events. Cox proportional hazards and Poisson regression models were used to estimate the relative risks (RRs) of CVD, myocardial infarction, ischemic heart disease (IHD), congestive heart failure (CHF), and stroke after adjusting for available sociodemographic and medical factors.

RESULTS

OA was an independent predictor of CVD. The adjusted RRs were 1.15 (95% confidence interval [95% CI] 1.04-1.27), 1.26 (95% CI 1.13-1.42), and 1.17 (95% CI 1.07-1.26) among older men, younger women, and older women, respectively. Analyses were stratified by age and sex due to statistically significant interactions between OA and age and sex. RRs among older men, younger women, and older women were 1.33 (95% CI 1.11-1.62), 1.66 (95% CI 1.37-2.01), and 1.45 (95% CI 1.22-1.72) for IHD, respectively, and 1.25 (95% CI 1.02-1.54), 1.29 (95% CI 1.00-1.68), and 1.20 (95% CI 1.03-1.39) for CHF, respectively. Compared to non-OA individuals, OA cases who underwent total joint replacements had a 26% increased risk of CVD.

CONCLUSION

This prospective longitudinal study suggests that OA is associated with an increased risk of CVD. Older men and adult women with OA had a higher risk of CVD, particularly IHD and CHF. Further studies are needed to confirm these results and to elucidate the potential biologic mechanisms.

Physician-delivered injection therapies for mechanical neck disorders: a systematic review update (non-oral, non-intravenous pharmacological interventions for neck pain)

Background:

Controversy persists regarding medicinal injections for mechanical neck disorders (MNDs).

Objectives:

To determine the effectiveness of physician-delivered injections on pain, function/disability, quality of life, global perceived effect and patient satisfaction for adults with MNDs.

Search Methods:

We updated our previous searches of CENTRAL, MEDLINE and EMBASE from December 2006 through to March 2012.

Selection Criteria:

We included randomized controlled trials of adults with neck disorders treated by physician-delivered injection therapies.

Data Collection and Analysis:

Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models.

Results:

We included 12 trials (667 participants). No high or moderate quality studies were found with evidence of benefit over control. Moderate quality evidence suggests little or no difference in pain or function/disability between nerve block injection of steroid and bupivacaine vs bupivacaine alone at short, intermediate and long-term for chronic neck pain. We found limited very low quality evidence of an effect on pain with intramuscular lidocaine vs control for chronic myofascial neck pain. Two low quality studies showed an effect on pain with anaesthetic nerve block vs saline immediately post treatment and in the short-term. All other studies were of low or very low quality with no evidence of benefit over controls.

Authors' Conclusions:

Current evidence does not confirm the effectiveness of IM-lidocaine injection for chronic mechanical neck pain nor anaesthetic nerve block for cervicogenic headache. There is moderate evidence of no benefit for steroid blocks vs controls for mechanical neck pain.

A methodological guide to performing a cost-utility study comparing surgical techniques

BACKGROUND

When recommending the adoption of a new surgical intervention as opposed to maintaining an old one, surgeons need to consider the opportunity cost, which is the value of the forgone benefits. To inform these decisions, surgeons can use economic analyses of surgical practices. Unfortunately, economic analyses conducted alongside randomized controlled trials in surgery are rare.

OBJECTIVES

The objective of the present study was to use data from a small randomized controlled trial to illustrate the methodology for a cost-utility analysis comparing two techniques of carpal tunnel release: open release without ('usual' technique) and with ('novel' technique) ligament reconstruction.

METHODS

Eighteen eligible patients were entered into this prospective study. Fifteen were followed to six weeks postoperatively. One day preoperatively, and five days, three weeks and six weeks postoperatively, patients completed a self-administered Health Utilities Index Mark 2-3 questionnaire (utilities) and a case report form from which resource utilization (cost) was collected. Utilities were expressed as quality-adjusted life weeks, a fraction of quality-adjusted life years.

RESULTS

The mean total cost of the usual technique was lower than the novel technique, and the mean quality-adjusted life week was higher, favouring the usual technique. Indirect costs were four to nine times higher than direct costs in both techniques.

CONCLUSION

The novel technique was more costly and less effective, and fell in the 'lose-lose' quadrant of the cost-effectiveness plane; it was rejected in favour of the usual technique. This methodology should be applied when deciding whether to adopt novel surgical techniques in plastic surgery to optimize scarce health care resources.

Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project

OBJECTIVES

To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched from 2006 to 2012.

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review.

MAIN RESULTS

We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability;

REVIEWERS' CONCLUSIONS

While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.

Low Level Laser Therapy (LLLT) for Neck Pain: A Systematic Review and Meta-Regression

PURPOSE

This systematic review update evaluated low level laser therapy (LLLT) for adults with neck pain.

METHODS

Computerized searches (root up to Feb 2012) included pain, function/disability, quality of life (QoL) and global perceived effect (GPE). GRADE, effect-sizes, heterogeneity and meta-regression were assessed.

RESULTS

Of 17 trials, 10 demonstrated high risk of bias. For chronic neck pain, there was moderate quality evidence (2 trials, 109 participants) supporting LLLT over placebo to improve pain/disability/QoL/GPE up to intermediate-term (IT). For acute radiculopathy, cervical osteoarthritis or acute neck pain, low quality evidence suggested LLLT improves ST pain/function/QoL over a placebo. For chronic myofascial neck pain (5 trials, 188 participants), evidence was conflicting; a meta-regression of heterogeneous trials suggests super-pulsed LLLT increases the chance of a successful pain outcome.

CONCLUSIONS

We found diverse evidence using LLLT for neck pain. LLLT may be beneficial for chronic neck pain/function/QoL. Larger long-term dosage trials are needed.

Risks and benefits of screening asymptomatic women for ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

We performed a systematic review and meta-analysis to quantify risks and benefits of screening asymptomatic women for ovarian cancer.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL, without language restrictions, from January 1, 1979 to February 5, 2012. Eligible studies randomly assigned asymptomatic women to screening or usual care. Two reviewers independently screened studies for eligibility, extracted data using a standardized, piloted extraction form, and assessed bias and strength of inference for each outcome using the GRADE framework. Chance-corrected agreement was calculated at each step, and disagreements were resolved through consensus.

RESULTS

Ten randomized trials proved eligible. Screening did not reduce all-cause mortality (relative risk (RR)=1.0, 95% confidence interval (CI) 0.96-1.06), ovarian cancer specific mortality (RR=1.08, 95% CI 0.84-1.38), or risk of diagnosis at an advanced stage (RR of diagnosis at FIGO stages III-IV=0.86, 95% CI 0.68-1.11). Transvaginal ultrasound resulted in a mean of 38 surgeries per ovarian cancer detected (95% CI 15.7-178.1) while screening with CA-125 led to 4 surgeries per ovarian cancer detected (95% CI 2.7-4.5). Surgery was associated with severe complications in 6% of women (95% CI 1%-11%). Quality of life was not affected by screening; however, women with false-positive results had increased cancer-specific distress compared to those with normal results (odds ratio (OR)=2.22, 95% CI 1.23-3.99).

CONCLUSIONS

Screening asymptomatic women for ovarian cancer does not reduce mortality or diagnosis at an advanced stage and is associated with unnecessary surgery.

Capture-mark-recapture to estimate the number of missed articles for systematic reviews in surgery

BACKGROUND

Systematic reviews are an important knowledge synthesis tool, but with new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis.

METHODS

This study tested capture-mark-recapture (CMR), an ecology-based technique, to estimate the total number of articles in the literature identified in a systematic review of adult trauma care quality indicators.

RESULTS

The systematic review included 40 articles identified from online searches and citation references. The CMR model suggested that 3 (95% confidence interval [CI]: 0 to 6) articles were missed and the database search provided 93% (one-sided 95% CI: ≥83%) of known articles for inclusion in the systematic review. The search order used for identifying the articles was optimal among the 24 that could have been used.

CONCLUSIONS

The CMR technique can be used in systematic reviews in surgery to estimate the closeness to capturing the total body of literature for a specific topic.

The relationship between osteoarthritis and cardiovascular disease in a population health survey: a cross-sectional study

OBJECTIVES

Our objective was to determine the relationship between osteoarthritis (OA) and heart diseases (myocardial infarction (MI), angina, congestive heart failure (CHF)) and stroke using population-based survey data.

DESIGN

Cross-sectional study.

SETTING

Canadian Community Health Survey (CCHS).

PARTICIPANTS

Adult participants in the CCHS cycles 1.1, 2.1 and 3.1 were included. CCHS provides nationally representative data on health determinants, health status and health system utilisation. We have identified 40 817 self-reported OA subjects and selected 1:1 matched non-OA respondents by age, sex and CCHS cycles.

MAIN OUTCOME MEASURES

Self-reported heart disease was the primary outcome and MI, angina, CHF and stroke were considered as secondary outcomes. Multivariable logistic regression models were used to estimate the ORs after adjusting for sociodemographic status, obesity, physical activity, smoking status, fruit and vegetable consumption, medication use, diabetes, hypertension and chronic obstructive pulmonary disease.

RESULTS

The mean age of OA cases was 66 years and 71.6% were women. OA exhibited increased odds of prevalent heart disease, and adjusted overall OR (95% CI) was 1.45 (1.36 to 1.54), 1.35 (1.21 to 1.50) among men and 1.51 (1.39 to 1.64) among women with OA. OA showed increased ORs for angina and CHF in both men and women, and for MI in women. ORs (95% CI) for men and women, respectively, were 1.08 (0.91 to 1.28) and 1.49 (1.28 to 1.75) for MI, 1.76 (1.43 to 2.17) and 1.84 (1.59 to 2.14) for angina, 1.50 (1.13 to 1.97) and 1.81 (1.49 to 2.21) for CHF, and 1.08 (0.83 to 1.40) and 1.13 (0.93 to 1.37) for stroke.

CONCLUSIONS

Prevalent OA was associated with self-reported heart disease, particularly angina, and CHF in both men and women, after controlling for established risk factors for these conditions. This study provides a rationale for further investigation of the association between OA and heart disease in longitudinal studies for investigating possible biological and behavioural mechanisms.

The general public's willingness to pay for tax increases to support unrestricted access to an Alzheimer's disease medication

BACKGROUND

Alzheimer's disease (AD) is a neurodegenerative disorder highlighted by progressive declines in cognitive and functional abilities.

OBJECTIVE

Our objective was to assess the general public's maximum willingness to pay ((M)WTP) for an increase in annual personal income taxes to fund unrestricted access to AD medications.

METHODS

We randomly recruited 500 Canadians nationally and used computer-assisted telephone interviewing to administer a questionnaire. The questionnaire contained four 'efficacy' scenarios describing an AD medication as capable of symptomatically treating cognitive decline or modifying disease progression. The scenarios also described the medication as having no adverse effects or a 30% chance of adverse effects. We randomized participants to order of scenarios and willingness-to-pay bid values; (M)WTP for each scenario was the highest accepted bid for that scenario. We conducted linear regression and bootstrap sensitivity analyses to investigate potential determinants of (M)WTP.

RESULTS

Mean (M)WTP was highest for the 'disease modification/no adverse effects' scenario ($Can130.26) and lowest for the 'symptomatic treatment/30% chance of adverse effects' scenario ($Can99.16). Bootstrap analyses indicated none of our potential determinants (e.g. age, sex) were associated with participants' (M)WTP.

CONCLUSIONS

The general public is willing to pay higher income taxes to fund unrestricted access to AD (especially disease-modifying) medications. Consequently, the public should favour placing new AD medications on public drug plans. As far as we are aware, no other study has elicited the general public's willingness to pay for AD medications.

The Diagnostic Validity of Clinical Tests in Temporomandibular Internal Derangement: A Systematic Review and Meta-analysis

PURPOSE

To assess the diagnostic validity of clinical tests for temporomandibular internal derangement relative to magnetic resonance imaging (MRI).

METHODS

MEDLINE and Embase were searched from 1994 through 2009. Independent reviewers conducted study selection; risk of bias was assessed using Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews (QUADAS); ≥9/14) and data abstraction. Overall quality of evidence was profiled using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Agreement was measured using quadratic weighted kappa (κw). Positive (+) or negative (-) likelihood ratios (LR) with 95% CIs were calculated and pooled using the DerSimonian-Laird method and a random-effects model when homogeneous (I(2)≥0.40, Q-test p≤0.10).

RESULTS

We selected 8 of 36 studies identified. There is very low quality evidence that deflection (+LR: 6.37 [95% CI, 2.13-19.03]) and crepitation (LR:5.88 [95% CI, 1.95-17.76]) as single tests and crepitation, deflection, pain, and limited mouth opening as a cluster of tests are the most valuable for ruling in internal derangement without reduction (+LR:6.37 [95% CI, 2.13-19.03]), (-LR:0.27 [95% CI, 0.11-0.64]) while the test cluster click, deviation, and pain rules out internal derangement with reduction (-LR: 0.09 [95% CI, 0.01-0.72]). No single test or cluster of tests was conclusive and of significant value for ruling in internal derangement with reduction.

CONCLUSIONS

Findings of this review will assist clinicians in deciding which diagnostic tests to use when internal derangement is suspected. The literature search revealed a lack of high-quality studies; further research with adequate description of patient populations, blinded assessments, and both sagittal and coronal MRI planes is therefore recommended.

Purpose: To assess the diagnostic validity of clinical tests for temporomandibular internal derangement relative to magnetic resonance imaging (MRI). Methods: MEDLINE and Embase were searched from 1994 through 2009. Independent reviewers conducted study selection; risk of bias was assessed using Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews (QUADAS); ≥9/14) and data abstraction. Overall quality of evidence was profiled using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Agreement was measured using quadratic weighted kappa (κw). Positive (+) or negative (−) likelihood ratios (LR) with 95% CIs were calculated and pooled using the DerSimonian–Laird method and a random-effects model when homogeneous (I²≥0.40, Q-test p≤0.10). Results: We selected 8 of 36 studies identified. There is very low quality evidence that deflection (+LR: 6.37 [95% CI, 2.13–19.03]) and crepitation (LR:5.88 [95% CI, 1.95–17.76]) as single tests and crepitation, deflection, pain, and limited mouth opening as a cluster of tests are the most valuable for ruling in internal derangement without reduction (+LR:6.37 [95% CI, 2.13–19.03]), (−LR:0.27 [95% CI, 0.11–0.64]) while the test cluster click, deviation, and pain rules out internal derangement with reduction (−LR: 0.09 [95% CI, 0.01–0.72]). No single test or cluster of tests was conclusive and of significant value for ruling in internal derangement with reduction. Conclusions: Findings of this review will assist clinicians in deciding which diagnostic tests to use when internal derangement is suspected. The literature search revealed a lack of high-quality studies; further research with adequate description of patient populations, blinded assessments, and both sagittal and coronal MRI planes is therefore recommended.

Dose-dependent development of depressive symptoms during adjuvant interferon-{alpha} treatment of patients with malignant melanoma

BACKGROUND

Adjuvant IFN-α treatment for patients with malignant melanoma is often complicated by depression. The influence of dosage, however, is unknown.

OBJECTIVE

The authors sought to elucidate this dosage effect.

METHOD

Using the Zung Self-Rating Depression Scale and the German Bf-S Self-Rating (Affectivity) Scale, the authors prospectively compared the frequency and severity of IFN-α-induced depressive symptoms between a group of 29 patients receiving low-dose and 17 patients getting high-dose induction therapy for 4 weeks.

RESULTS

Patients receiving high-dose induction treatment had significantly higher depression scores after 4 weeks, and significantly more patients in the high-dose group developed depression.

CONCLUSION

The authors concluded that frequency and severity of IFN-α-associated depression during melanoma treatment are dose-dependent.

Systematic review of radioguided surgery for non-palpable breast cancer

BACKGROUND

This systematic review examines whether radioguided localization surgery (RGL) (radioguided occult lesion localization - ROLL and radioguided seed localization - RSL) for non-palpable breast cancer lesions produces lower positive margin rates than standard wire-guided localization surgery.

METHODS

We performed a comprehensive literature review to identify clinical studies using either ROLL or RSL. Included studies examined invasive or in situ BC and reported pathologically assessed margin status or specimen volume/weight. Two reviewers independently assessed study eligibility and quality and abstracted relevant data on patient and surgical outcomes. Quantitative data analyses were performed.

RESULTS

Fifty-two clinical studies on ROLL (n = 46) and RSL (n = 6) were identified. Twenty-seven met our inclusion criteria: 12 studies compared RGL to WGL and 15 studies were single cohorts using RGL. Ten studies were included in the quantitative analyses. Data for margin status and re-operation rates from 4 randomized controlled trials (RCT; n = 238) and 6 cohort studies were combined giving a combined odds ratio (OR) of 0.367 and 95% confidence interval (CI): 0.277 to 0.487 (p < 0.001) for margins status and OR 0.347, 95% CI: 0.250 to 0.481 (p < 0.001) for re-operation rates.

CONCLUSIONS

The results of this systematic review of RGL versus WGL demonstrate that RGL technique produces lower positive margins rates and fewer re-operations. While this review is limited by the small size and quality of RCTs, the odds ratios suggest that RGL may be a superior technique to guide surgical resection of non-palpable breast cancers. These results should be confirmed by larger, multi-centered RCTs.

Data withdrawal in randomized controlled trials: Defining the problem and proposing solutions: a commentary

It is not uncommon for a participant to withdraw from a randomized controlled trial (RCT). The withdrawal of a participant results in missing data and the potential for withdrawal bias. Data withdrawal, or a request from a participant to withdraw all of their previously collected data from a study, is particularly problematic because it leaves little opportunity to characterize or statistically address those that have withdrawn to minimize withdrawal bias. The aim of this commentary is to (1) provide a synthesis of available information on the ethical and methodological issues related to data withdrawal in RCTs and (2) provide some suggestions on how to minimize the impact of data withdrawal during the execution or analysis phases of an RCT. We searched PubMed, EMBASE and JSTOR for published articles on data withdrawal. In addition, we used internet sources as an additional tool to identify content on data withdrawal from research ethics guidelines, legislation, research ethics boards, funding agencies, professional organizations and researchers. We did not find any definitive guidelines for dealing with data withdrawal. We propose recommendations for minimizing the occurrence of data withdrawal, including explicit and clear descriptions in consent forms of how data will be handled after participant withdrawal. We also suggest using imputation techniques to deal with the missing data during analysis. The current commentary can be used to minimize the impact of data withdrawal in RCTs.

The capture-mark-recapture technique can be used as a stopping rule when searching in systematic reviews

OBJECTIVE

Researchers have no empirically based search stopping rule when looking for potentially relevant articles for inclusion in systematic reviews. We tested a stopping strategy based on capture-mark-recapture (CMR; i.e., the Horizon Estimate) statistical modeling to estimate the total number of articles in the domain of clinical decision support tools for osteoporosis disease management using four large bibliographic databases (Medline, EMBASE, CINAHL, and EBM reviews).

STUDY DESIGN AND SETTING

Retrospective evaluation of the Horizon Estimate using a systematic review of randomized controlled trials (RCTs) at two levels of article screening: title and abstract (1,246 potentially relevant articles) and full text (42 potentially relevant articles).

RESULTS

The CMR model suggests that the total number of potential articles was 1,838 for the first level of screening, and 49 for the full-text level. The four databases provided 68% of known articles for the first level of screening and 81% for full-text screening.

CONCLUSIONS

The CMR technique can be used in systematic reviews to estimate the closeness to capturing the total body of literature on a given topic. More studies are needed to objectively determine the usefulness of Horizon Estimates as a stopping rule strategy for systematic review searching.

Estimating the Horizon of articles to decide when to stop searching in systematic reviews: an example using a systematic review of RCTs evaluating osteoporosis clinical decision support tools

Researchers conducting systematic reviews need to search multiple bibliographic databases such as MEDLINE and EMBASE. However, researchers have no rational search stopping rule when looking for potentially-relevant articles. We empirically tested a stopping rule based on the concept of capture-mark-recapture (CMR), which was first pioneered in ecology. The principles of CMR can be adapted to systematic reviews and meta-analyses to estimate the Horizon of articles in the literature with its confidence interval. We retrospectively tested this Horizon Estimation using a systematic review of randomized controlled trials (RCTs) that evaluated clinical decision support tools for osteoporosis disease management. The Horizon Estimation was calculated based on 4 bibliographic databases that were included as the main data sources for the review in the following order: MEDLINE, EMBASE, CINAHL, and EBM Reviews. The systematic review captured 68% of known articles from the 4 data sources, which represented 592 articles that were estimated as missing from the Horizon.

A comprehensive appropriateness of prescribing questionnaire was validated by nominal consensus group

OBJECTIVE

To develop and validate a comprehensive Appropriateness of Prescribing Evaluation Questionnaire (APEQ) suitable for human and computer use.

STUDY DESIGN AND SETTING

This study was part of an ongoing research program examining the effectiveness and cost-effectiveness of computerized prescribing decision support for providers, patients, and drug policy. A nominal group consensus process involved physicians, both primary care physicians and specialists, pharmacists, drug plan managers, patients, patient advocates, and pharmaceutical industry. Structured case scenarios of musculoskeletal problems were used to evaluate APEQ's validity and responsiveness.

RESULTS

Seventeen panelists evaluated 72 patient scenarios in two rounds. Their ratings of appropriateness, assessed by ANOVA, showed significant agreement with the experts' scores in the two rounds, which evaluated appropriateness and responsiveness, respectively. Interrater and intrarater agreement was moderate to good.

CONCLUSION

This formal assessment suggests that APEQ has reasonable validity, reliability, and responsiveness. Such tools could be very useful in e-prescribing and e-claims reimbursement environments and should be further explored.

Medicinal and injection therapies for mechanical neck disorders

BACKGROUND

Controversy persists regarding medicinal therapies and injections.

OBJECTIVES

To determine the effects of medication and injections on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash.

SEARCH STRATEGY

We searched CENTRAL, MANTIS, CINAHL from their start to May 2006; MEDLINE and EMBASE to December 2006. We scrutinised reference lists for other trials.

SELECTION CRITERIA

We included randomised controlled trials with adults with neck disorders, with or without associated headache or radicular findings. We considered medicinal and injection therapies, regardless of route of administration.

DATA COLLECTION AND ANALYSIS

Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models.

MAIN RESULTS

We found 36 trials that examined the effects of oral NSAIDs, psychotropic agents, steroid injections, and anaesthetic agents. Trials had a mean of 3.1 on the Jadad Scale for methodological quality; 70% were high quality. For acute whiplash, administering intravenous methylprednisolone within eight hours of injury reduced pain at one week (SMD -0.90, 95% CI -1.57 to -0.24), and sick leave but not pain at six months compared to placebo in one trial. For chronic neck disorders at short-term follow-up, intramuscular injection of lidocaine was superior to placebo (SMD -1.36, 95% CI -1.93 to -0.80); NNT 3, treatment advantage 45% and dry needling, but similar to ultrasound in one trial each. In chronic neck disorders with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain and improved function more than when given by intramuscular route at one-year follow-up, in one trial. In subacute and chronic neck disorders, muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits. In participants with chronic neck disorders with or without radicular findings or headache, there was moderate evidence from five high quality trials that Botulinum toxin A intramuscular injections had similar effects to saline in improving pain (pooled SMD: -0.39, 95%CI -1.25 to 0.47), disability or global perceived effect.

AUTHORS' CONCLUSIONS

The major limitations are the lack of replication of the findings and sufficiently large trials. There is moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial. Lidocaine injection into myofascial trigger points appears effective in two trials. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.

Mortality in patients with necrotizing fasciitis

BACKGROUND

The prognostic factors that determine outcome in patients with necrotizing fasciitis remain poorly understood. The aim of this study was to analyze the variables that affect the mortality and morbidity of patients with necrotizing fasciitis and to create a simple method for estimating the probability of mortality.

METHODS

The authors undertook a retrospective review of all patients with necrotizing fasciitis treated in three tertiary care hospitals in Ontario, Canada, between January of 1994 and June of 2001. Demographic, comorbid illness, and disease-specific data were collated and analyzed for associations with outcome. Using logistic regression analysis, probability estimates for the prediction of mortality were developed, based on three contributing independent factors.

RESULTS

Ninety-nine patients satisfied the inclusion criteria. Overall mortality was 20 percent. Sixteen patients suffered from amputation or organ loss. The most common comorbidities were diabetes (30 percent), immunocompromised status (17 percent), and chickenpox (11 percent). Advanced age (odds ratio, 1.04; 95 percent confidence interval, 1.01 to 1.08; p = 0.012), streptococcal toxic shock syndrome (odds ratio, 10.54; 95 percent confidence interval, 2.80 to 39.44; p < 0.001), and immunocompromised status (odds ratio, 3.97; 95 percent confidence interval, 1.04 to 15.19; p = 0.044) were independent predictors of mortality and were used to design a formula for the probability of mortality.

CONCLUSIONS

Age, streptococcal toxic shock syndrome, and immune status are significant determinants of mortality and can predict the probability of death from necrotizing fasciitis soon after admission. This objective information can guide clinicians in communication with patients and in making clinical decisions.

Massage for mechanical neck disorders: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To assess the effects of massage on pain, function, patient satisfaction, cost of care, and adverse events in adults with neck pain.

SUMMARY OF BACKGROUND DATA

Neck pain is common, disabling, and costly. Massage is a commonly used modality for the treatment of neck pain.

METHODS

We searched several databases without language restriction from their inception to September 2004. We included randomized and quasirandomized trials. Two reviewers independently identified studies, abstracted data, and assessed quality. We calculated the relative risks and standardized mean differences on primary outcomes. Trials could not be statistically pooled because of heterogeneity in treatment and control groups. Therefore, a levels-of-evidence approach was used to synthesize results.

RESULTS

Overall, 19 trials were included, with 12/19 receiving low-quality scores. Descriptions of the massage intervention, massage professional's credentials, or experience were frequently missing. Six trials examined massage as a stand-alone treatment. The results were inconclusive. Results were also inconclusive in 14 trials that used massage as part of a multimodal intervention because none were designed such that the relative contribution of massage could be ascertained.

CONCLUSIONS

No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain. Pilot studies are needed to characterize massage treatment (frequency, duration, number of sessions, and massage technique) and establish the optimal treatment to be used in subsequent larger trials that examine the effect of massage as either a stand-alone treatment or part of a multimodal intervention. For multimodal interventions, factorial designs are needed to determine the relative contribution of massage. Future reports of trials should improve reporting of the concealment of allocation, blinding of outcome assessor, adverse events, and massage characteristics. Standards of reporting for massage interventions, similar to Consolidated Standards of Reporting Trials, are needed. Both short and long-term follow-up are needed.

BLISS index for analyzing knee osteoarthritis trials data

OBJECTIVES

Different pain thresholds were investigated, using the WOMAC Pain Scale (WOMAC-P) to determine if they could differentiate between treatment groups (hylan G-F 20 vs. appropriate care) at low and very low levels of state attainment in patients with knee osteoarthritis (OA). A method, termed the BLISS (Bellamy et al. Low Intensity Symptom State-attainment) Index, for analyzing OA knee clinical trials data, was proposed.

STUDY DESIGN AND SETTING

Five analyses were performed: time to first BLISS day, BLISS days over 12 months, patients with a BLISS response at month 12, patients with a BLISS response at any time, and number of BLISS periods over 12 months. For each analysis, five levels of WOMAC-P were examined: <or=5 normalized units (NU), <or=10, <or=15, <or=20, and <or=25 (higher=more pain).

RESULTS

More patients in the hylan G-F 20 group achieved BLISS states in all five analyses. These differences were statistically significant for all pain threshold levels except <or=5 NU.

CONCLUSION

Five methods of measuring BLISS attainment using four prespecified threshold levels of pain were able to statistically discriminate between treatment groups. This method may potentially provide an approach, to defining which patients not only improve but also achieve a good state of health, at low and very low levels of pain intensity. BLISS-10 is a therapeutically attainable very low symptom state at which clinically important, statistically significant between-group differences are detectable, and therefore may provide a benchmark against which therapeutic interventions can be assessed. However, the value to patients, of this and other low and very low intensity pain states, requires further elaboration.

Perioperative use of the hands-free technique: a semistructured interview study

OCCUPATIONALLY CONTRACTED bloodborne infections are preventable, but the use of many protective measures remains limited. THERE IS GROWING EVIDENCE that the use of the hands-free technique (HFT) to pass sharp items during surgical procedures is effective in protecting against sharps injury and bloody contamination. RESEARCHERS CONDUCTED in-depth telephone interviews to explore 20 health care providers' knowledge and use of the HFT. MOST OF THE INTERVIEWEES did not regularly use the HFT, and some were resistant to its use.