Bone classification: an objective scale of bone density using the computerized tomography scan

Dental implants are subject to masticatory loads of varying magnitude. Implant performance is closely related to load transmission at the bone-to-implant interface where bone quality will be highly variable. The type and architecture of bone is known to influence its load bearing capacity and it has been demonstrated that poorer quality bone is associated with higher failure rates. To date, bone classifications have only provided rough subjective methods for pre-operative assessment, which can prove unreliable. The results of an extensive analysis of computerized tomography scans using Simplant software (Columbia Scientific Inc., Columbia, MD, USA) demonstrate that an objective scale of bone density based on the Houndsfield scale, can be established and that there is a strong correlation between bone density value and subjective quality score (P = 0.002) as well as between the bone density score and the region of the mouth (P < 0.001).

Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial

BACKGROUND

The relative risks and benefits of starting or withholding antiepileptic drug treatment in patients with few or infrequent seizures are unclear. We sought to compare policies of immediate versus deferred treatment in such patients and to assess the effects of these policies on short-term recurrence and long-term outcomes.

METHODS

We undertook an unmasked, multicentre, randomised study of immediate and deferred antiepileptic drug treatment in 1847 patients with single seizures and early epilepsy. Outcomes comprised time to first, second, and fifth seizures; time to 2-year remission; no seizures between years 1 and 3 and between years 3 and 5 after randomisation; and quality of life. Analysis was by intention to treat.

FINDINGS

404 patients invited to join the trial did not consent to randomisation; 722 were subsequently assigned immediate treatment with antiepileptic drugs and 721 were assigned deferred treatment. Immediate treatment increased time to first seizure (hazard ratio 1.4 [95% CI 1.2 to 1.7]), second seizure (1.3 [1.1 to 1.6]), and first tonic-clonic seizure (1.5 [1.2 to 1.8]). It also reduced the time to achieve 2-year remission of seizures (p=0.023). At 5-years follow-up, 76% of patients in the immediate treatment group and 77% of those in the deferred treatment group were seizure free between 3 and 5 years after randomisation (difference -0.2% [95% CI -5.8% to 5.5%]). The two policies did not differ with respect to quality of life outcomes or serious complications.

INTERPRETATION

Immediate antiepileptic drug treatment reduces the occurrence of seizures in the next 1-2 years, but does not affect long-term remission in individuals with single or infrequent seizures.

Relation between lipophilicity and pharmacological behavior of minocycline, doxycycline, tetracycline, and oxytetracycline in dogs

Four tetracyclines were studied in dogs to determine the relation between their lipophilicity and various other pharmacological characteristics. Lipid solubility correlated inversely with the mean concentration of drug in arterial plasma and renal uptake and excretion, and directly with the biliary concentration gradient (level in bile/level of free drug in serum). Only the more lipophilic congeners minocycline and doxycycline passed the blood-brain and blood-ocular barriers in detectable concentrations. Mean levels of minocycline in the brain exceeded those of doxycycline by almost threefold; the difference was of borderline statistical significance (P = 0.05 to 0.1). Lipophilicity correlated inversely with the concentration of antibiotic in renal medulla but not in renal cortex or in the liver. When intestinal loops containing saline, milk, or 10% Gelusil were studied, the only combination exhibiting striking intraluminal accumulation was doxycycline in milk. These results indicate that lipophilicity correlates with many, but not all, of the transport characteristics of tetracycline antibiotics.

Outcome selection bias in meta-analysis

Publication bias has been previously identified as a threat to the validity of a meta-analysis. Recently, new evidence has documented an additional threat to validity, the selective reporting of trial outcomes within published studies. Several diseases have several possible measures of outcome. Some articles might report only a selection of those outcomes, perhaps those with statistically significant results. In this article, we review this problem while addressing the questions: what is within-study selective reporting? how common is it? why is it done? how can it mislead? how can it be detected?, and finally, what is the solution? We recommend that both publication bias and selective reporting should be routinely investigated in systematic reviews.

Frequency and reasons for outcome reporting bias in clinical trials: interviews with trialists

OBJECTIVES

To provide information on the frequency and reasons for outcome reporting bias in clinical trials.

DESIGN

Trial protocols were compared with subsequent publication(s) to identify any discrepancies in the outcomes reported, and telephone interviews were conducted with the respective trialists to investigate more extensively the reporting of the research and the issue of unreported outcomes.

PARTICIPANTS

Chief investigators, or lead or coauthors of trials, were identified from two sources: trials published since 2002 covered in Cochrane systematic reviews where at least one trial analysed was suspected of being at risk of outcome reporting bias (issue 4, 2006; issue 1, 2007, and issue 2, 2007 of the Cochrane library); and a random sample of trial reports indexed on PubMed between August 2007 and July 2008.

SETTING

Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

MAIN OUTCOME MEASURES

Frequency of incomplete outcome reporting-signified by outcomes that were specified in a trial's protocol but not fully reported in subsequent publications-and trialists' reasons for incomplete reporting of outcomes.

RESULTS

268 trials were identified for inclusion (183 from the cohort of Cochrane systematic reviews and 85 from PubMed). Initially, 161 respective investigators responded to our requests for interview, 130 (81%) of whom agreed to be interviewed. However, failure to achieve subsequent contact, obtain a copy of the study protocol, or both meant that final interviews were conducted with 59 (37%) of the 161 trialists. Sixteen trial investigators failed to report analysed outcomes at the time of the primary publication, 17 trialists collected outcome data that were subsequently not analysed, and five trialists did not measure a prespecified outcome over the course of the trial. In almost all trials in which prespecified outcomes had been analysed but not reported (15/16, 94%), this under-reporting resulted in bias. In nearly a quarter of trials in which prespecified outcomes had been measured but not analysed (4/17, 24%), the "direction" of the main findings influenced the investigators' decision not to analyse the remaining data collected. In 14 (67%) of the 21 randomly selected PubMed trials, there was at least one unreported efficacy or harm outcome. More than a quarter (6/21, 29%) of these trials were found to have displayed outcome reporting bias.

CONCLUSION

The prevalence of incomplete outcome reporting is high. Trialists seemed generally unaware of the implications for the evidence base of not reporting all outcomes and protocol changes. A general lack of consensus regarding the choice of outcomes in particular clinical settings was evident and affects trial design, conduct, analysis, and reporting.

Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial

OBJECTIVE

To assess the effectiveness and safety of melatonin in treating severe sleep problems in children with neurodevelopmental disorders.

DESIGN

12 week double masked randomised placebo controlled phase III trial.

SETTING

19 hospitals across England and Wales.

PARTICIPANTS

146 children aged 3 years to 15 years 8 months were randomised. They had a range of neurological and developmental disorders and a severe sleep problem that had not responded to a standardised sleep behaviour advice booklet provided to parents four to six weeks before randomisation. A sleep problem was defined as the child not falling asleep within one hour of lights out or having less than six hours' continuous sleep.

INTERVENTIONS

Immediate release melatonin or matching placebo capsules administered 45 minutes before the child's bedtime for a period of 12 weeks. All children started with a 0.5 mg capsule, which was increased through 2 mg, 6 mg, and 12 mg depending on their response to treatment.

MAIN OUTCOME MEASURES

Total sleep time at night after 12 weeks adjusted for baseline recorded in sleep diaries completed by the parent. Secondary outcomes included sleep onset latency, assessments of child behaviour, family functioning, and adverse events. Sleep was measured with diaries and actigraphy.

RESULTS

Melatonin increased total sleep time by 22.4 minutes (95% confidence interval 0.5 to 44.3 minutes) measured by sleep diaries (n=110) and 13.3 (-15.5 to 42.2) measured by actigraphy (n=59). Melatonin reduced sleep onset latency measured by sleep diaries (-37.5 minutes, -55.3 to -19.7 minutes) and actigraphy (-45.3 minutes, -68.8 to -21.9 minutes) and was most effective for children with the longest sleep latency (P=0.009). Melatonin was associated with earlier waking times than placebo (29.9 minutes, 13.6 to 46.3 minutes). Child behaviour and family functioning outcomes showed some improvement and favoured use of melatonin. Adverse events were mild and similar between the two groups.

CONCLUSIONS

Children gained little additional sleep on melatonin; though they fell asleep significantly faster, waking times became earlier. Child behaviour and family functioning outcomes did not significantly improve. Melatonin was tolerable over this three month period. Comparisons with slow release melatonin preparations or melatonin analogues are required.

TRIAL REGISTRATION

ISRCT No 05534585.

Insecticide-treated nets for preventing malaria in pregnancy

BACKGROUND

Malaria in pregnancy is associated with adverse consequences for mother and fetus. Protection with insecticide-treated nets (ITNs) during pregnancy is widely advocated, but evidence of their benefit has been inconsistent.

OBJECTIVES

To compare the impact of ITNs with no nets or untreated nets on preventing malaria in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (January 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to January 2006), EMBASE (1974 to January 2006), LILACS (1982 to January 2006), and reference lists. We also contacted researchers working in the field.

SELECTION CRITERIA

Individual and cluster randomized controlled trials of ITNs in pregnant women.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials for methodological quality and extracted data. Data were combined using the generic inverse variance method.

MAIN RESULTS

Six randomized controlled trials were identified, five of which met the inclusion criteria: four trials from sub-Saharan Africa compared ITNs with no nets, and one trial from Asia compared ITNs with untreated nets. Two trials randomized individual women and three trials randomized communities. In Africa, ITNs, compared with no nets, reduced placental malaria in all pregnancies (relative risk (RR) 0.79, 95% confidence interval (CI) 0.63 to 0.98). They also reduced low birthweight (RR 0.77, 95% CI 0.61 to 0.98) and stillbirths/abortions in the first to fourth pregnancy (RR 0.67, 95% CI 0.47 to 0.97), but not in women with more than four previous pregnancies. For anaemia and clinical malaria, results tended to favour ITNs, but the effects were not significant. In Thailand, one trial randomizing individuals to ITNs or untreated nets showed a significant reduction in anaemia and stillbirths/abortions in all pregnancies but not for clinical malaria or low birthweight.

AUTHORS' CONCLUSIONS

ITNs have a beneficial impact on pregnancy outcome in malaria-endemic regions of Africa when used by communities or by individual women. No further trials of ITNs in pregnancy are required in sub-Saharan Africa. Further evaluation of the potential impact of ITNs is required in areas with less intense and Plasmodium vivax transmission in Asia and Latin America.

Supporting mental health nurses to address the physical health needs of people with serious mental illness in acute inpatient care settings

There is overwhelming evidence that the physical health needs of those with serious mental illness have been neglected by health service professionals. Mental health nurses (MHNs) could play a key role in meeting these needs particularly during hospital admissions, yet they are uncertain about their role, have variable levels of confidence and lack appropriate skills and training. This study investigated MHNs' views and practices of physical health management for adults receiving acute inpatient treatment and found a difference between MHNs' perceived responsibility and their practice, which highlighted a need for role clarification and further skills training.

Identification and impact of outcome selection bias in meta-analysis

The systematic review community has become increasingly aware of the importance of addressing the issues of heterogeneity and publication bias in meta-analyses. A potentially bigger threat to the validity of a meta-analysis appears relatively unnoticed. The within-study selective reporting of outcomes, defined as the selection of a subset of the original variables recorded for inclusion in publication of trials, can theoretically have a substantial impact on the results. A cohort of meta-analyses on the Cochrane Library was reviewed to examine how often this form of within-study publication bias was suspected and explained some of the evident funnel plot asymmetry. In cases where the level of suspicion was high, sensitivity analysis was undertaken to assess the robustness of the conclusion to this bias. Although within-study selection was evident or suspected in several trials, the impact on the conclusions of the meta-analyses was minimal. This paper deals with the identification of, sensitivity analysis for, and impact of within-study selective reporting in meta-analysis.

Exploring the concept of recovery in schizophrenia

The concept of recovery in psychosis has gained much momentum in recent years in the UK. Current government policy describes its underpinning philosophy as the way forward for mental health services. Many mental health professionals now claim to embrace this concept yet fail to make the desired impact upon the care and treatment of individuals with schizophrenia. This article reviews some of the literature and explores what the concept of recovery means. The formal evidence will be augmented with personal accounts about recovery written by individuals who have schizophrenia. In doing so the main components that appear to have influenced the recovery process will be highlighted, and the implications for mental health nurses and practitioners will be discussed.

The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of central venous catheters (CVCs) treated with anti-infective agents in preventing catheter-related bloodstream infection (CRBSI).

DATA SOURCES

Major electronic databases were searched from 1985 to August 2005.

REVIEW METHODS

The systematic clinical and economic reviews were conducted according to accepted procedures. Only full economic evaluations (synthesis of costs and benefits) comparing the use of anti-infective central venous catheters (AI-CVCs) with untreated CVCs or other treated catheters were selected for inclusion in the economic review.

RESULTS

A total of 32 trials met the clinical inclusion criteria. Seven different types of AI-CVC were identified, with the most frequently tested being chlorhexidine and silver sulfadiazine (CHSS) (externally treated), CHSS (externally and internally treated) and minocycline rifampicin (internally and externally treated). In general, the trials were of a poor quality in terms of reported methodology, microbiological relevance and control of confounding variables. The pooled result suggests a statistically significant advantage for AI-CVCs in comparison to standard catheters in reducing CRBSI [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.34 to 0.60, 24 studies, I-squared = 0%, fixed effects]. Analysis by subgroups of catheters demonstrates that antibiotic-treated catheters and catheters treated internally and externally decrease CRBSI rates significantly (OR 0.26, 95% CI 0.15 to 0.46, six studies, I-squared = 0%, fixed effects, and OR 0.43, 95% CI 0.26 to 0.70, nine studies, I-squared = 0%, fixed effects, respectively). Catheters treated only externally demonstrate a wider CI and non-significant effect (OR 0.67, 95% CI 0.43 to 1.06, nine studies, I-squared = 0%, fixed effects). A treatment effect was also found for trials with an average duration of between 5 and 12 days, and for the one study with a mean duration of over 20 days. There was a statistically significant treatment effect for both femoral and jugular insertion sites and for those studies reporting a mix of insertion sites. The treatment effect was not observed in trials using exclusively subclavian insertion sites. Of the four trials that compared treated catheters, one reported a benefit of antibiotic-treated catheters over catheters treated externally with CHSS. All three sensitivity analyses testing for study design differences reported a statistically significant treatment effect. The review was limited owing to the quality of the trials included, marked differences in the definitions and methods of diagnosis of CRBSI, and inconsistent reporting of risk factors and patient population factors. Furthermore, two-thirds of trials were commercially funded. The economic performance (cost-effectiveness and potential cost-savings) of using AI-CVCs to reduce the number of CRBSIs in patients requiring a CVC was also reviewed. Results show that the use of AI-CVCs instead of standard CVCs can lead to a reduction in CRBSIs and decreased medical costs. To complement the reviews, a basic decision-analytic model was constructed to explore a range of possible scenarios for the NHS in England and Wales. Results show that for every patient who receives an AI-CVC there is an estimated cost-saving of 138.20 pounds. The multivariate sensitivity analyses estimate potentially large cost-savings, depending on the size of the population, under a wide range of cost and clinical assumptions. However, those considering the purchase of AI-CVCs should ensure that their patient populations and the important characteristics of local clinical practice are indeed similar to those described in this economic evaluation.

CONCLUSIONS

Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective. Pragmatic research related to the effectiveness of bundles of care that may reduce rates of CRBSI is also warranted.

A randomised controlled trial examining the longer-term outcomes of standard versus new antiepileptic drugs. The SANAD trial

OBJECTIVES

To compare clinicians' choice of one of the standard epilepsy drug treatments (carbamazepine or valproate) versus appropriate comparator new drugs.

DESIGN

A clinical trial comprising two arms, one comparing new drugs in carbamazepine and the other with valproate.

SETTING

A multicentre study recruiting patients with epilepsy from hospital outpatient clinics.

PARTICIPANTS

Patients with an adequately documented history of two or more clinically definite unprovoked epileptic seizures within the last year for whom treatment with a single antiepileptic drug represented the best therapeutic option.

INTERVENTIONS

Arm A was carbamazepine (CBZ) versus gabapentin (GBP) versus lamotrigine (LTG) versus oxcarbazepine (OXC) versus topiramate (TPM). Arm B valproate (VPS) versus LTG versus TPM.

MAIN OUTCOME MEASURES

Time to treatment failure (withdrawal of the randomised drug for reasons of unacceptable adverse events or inadequate seizure control or a combination of the two) and time to achieve a 12-month remission of seizures. Time from randomisation to first seizure, 24-month remission of seizures, incidence of clinically important adverse events, quality of life (QoL) outcomes and health economic outcomes were also considered.

RESULTS

Arm A recruited 1721 patients (88% with symptomatic or cryptogenic partial epilepsy and 10% with unclassified epilepsy). Arm B recruited 716 patients (63% with idiopathic generalised epilepsy and 25% with unclassified epilepsy). In Arm A LTG had the lowest incidence of treatment failure and was statistically superior to all drugs for this outcome with the exception of OXC. Some 12% and 8% fewer patients experienced treatment failure on LTG than CBZ, the standard drug, at 1 and 2 years after randomisation, respectively. The superiority of LTG over CBZ was due to its better tolerability but there is satisfactory evidence indicating that LTG is not clinically inferior to CBZ for measures of its efficacy. No consistent differences in QoL outcomes were found between treatment groups. Health economic analysis supported LTG being preferred to CBZ for both cost per seizure avoided and cost per quality-adjusted life-year gained. In Arm B for time to treatment failure, VPS, the standard drug, was preferred to both TPM and LTG, as it was the drug least likely to be associated with treatment failure for inadequate seizure control and was the preferred drug for time to achieving a 12-month remission. QoL assessments did not show any between-treatment differences. The health economic assessment supported the conclusion that VPS should remain the drug of first choice for idiopathic generalised or unclassified epilepsy, although there is a suggestion that TPM is a cost-effective alternative to VPS.

CONCLUSIONS

The evidence suggests that LTG may be a clinical and cost-effective alternative to the existing standard drug treatment, CBZ, for patients diagnosed as having partial seizures. For patients with idiopathic generalised epilepsy or difficult to classify epilepsy, VPS remains the clinically most effective drug, although TPM may be a cost-effective alternative for some patients. Three new antiepileptic drugs have recently been licensed in the UK for the treatment of epilepsy (levetiracetam, zonisamide and pregabalin), therefore these drugs should be compared in a similarly designed trial.

Quality of life outcomes of immediate or delayed treatment of early epilepsy and single seizures

OBJECTIVE

To compare the impact of policies of immediate vs deferred treatment in patients with few or infrequent seizures on quality of life (QoL) outcomes.

METHODS

We conducted a multicenter, randomized, unblinded study of immediate and deferred treatment. QoL data were collected by mail, using validated measures, for participants living in the UK and without major learning disability. Baseline questionnaires were returned by 441 adult patients; 333 returned 2-year follow-up questionnaires. This analysis is based on 331 patients (162 randomized to immediate, 169 to deferred treatment) returning both baseline and 2-year questionnaires.

RESULTS

There were no significant differences at 2 years in QoL outcomes by treatment group. Patients randomized to deferred treatment were no more likely to report impairments in general health, cognitive function, psychological well-being, or social function. The one area of functioning affected was driving, where those randomized to deferred treatment were disadvantaged. There were clear QoL impacts both of taking antiepileptic drugs and, to an even greater extent, of continuing seizures.

CONCLUSIONS

In treatment uncertain patients, there is a clear trade-off between adverse effects of seizures and adverse effects of taking antiepileptic drugs, i.e., neither policy examined in our study was associated with overall quality of life gains or losses longer term.

Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations

BACKGROUND

Chronic suppurative otitis media (CSOM) causes ear discharge and impairs hearing.

OBJECTIVES

To compare systemic antibiotics and topical antiseptics or antibiotics (excluding steroids) for treating chronically discharging ears with an underlying eardrum perforation (CSOM).

SEARCH STRATEGY

The Cochrane ENT Disorders Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 1, 2005), MEDLINE (January 1951 to March 2005), EMBASE (January 1974 to March 2005), LILACS (January 1982 to March 2005), AMED (1985 to March 2005), CINAHL (January 1982 to March 2005), OLDMEDLINE (January 1958 to December 1965) PREMEDLINE, Metadatabase of registers of ongoing trials (mRCT), and article references.

SELECTION CRITERIA

Randomised controlled trials; any systemic versus topical treatment (excluding steroids); participants with CSOM.

DATA COLLECTION AND ANALYSIS

One author assessed eligibility and quality, extracted data, entered data into RevMan; two authors provided a second assessment of titles and abstracts, and inputted where there was ambiguity. We contacted investigators for clarifications.

MAIN RESULTS

Nine trials (833 randomised participants; 842 analysed participants or ears). CSOM definitions and severity varied; some included mastoid cavity infections, other diagnoses, or complications. Methodological quality varied; generally poorly reported, follow-up short, handling of bilateral disease inconsistent. Topical quinolone antibiotics were better than systemic antibiotics at clearing discharge at 1-2 weeks: relative risks (RR) were, 3.21 (95% confidence interval (CI) 1.88 to 5.49) using systemic non-quinolone antibiotics (2 trials, N = 116), and 3.18 (1.87 to 5.43) using systemic quinolone (3 trials, N = 175); or 2.75 (1.38 to 5.46) in favour of systemic plus topical quinolone over systemic quinolone alone (2 trials, N = 90). No statistically significant benefit was seen at 2-4 weeks for topical non-quinolone antibiotic (without steroids) or topical antiseptic over systemic antibiotics (mostly non-quinolones), but numbers were small: one trial tested topical non-quinolones (N = 31); two tested antiseptics (N = 152). No benefit of adding systemic to topical treatment at 1-2 weeks was detected either, although evidence was limited (three trials, N = 204). Evidence regarding safety was generally weak. Adverse events reported were generally mild, although hearing worsened by ototoxicity (damaging auditory hair cells) was seen with chloramphenicol drops (non-quinolone antibiotic).

AUTHORS' CONCLUSIONS

Topical quinolone antibiotics can clear aural discharge better than systemic antibiotics; topical non-quinolone antibiotic (without steroids) or antiseptic results are less clear. Evidence regarding safety was weak. Further studies should clarify topical non-quinolones and antiseptic effectiveness, assess longer-term outcomes (for resolution, healing, hearing, or complications), and include further safety assessments, particularly to clarify the risks of ototoxicity and whether there may be fewer adverse events with topical quinolones than other topical or systemic treatments.

Family work in first-onset psychosis: a literature review

Family intervention may be helpful for people with psychosis. We reviewed the literature for family intervention for people with a first-onset psychosis. There is limited and conflicting evidence of the efficacy of family intervention for this population. Definitive randomized controlled trials are required to establish the efficacy. At this time, evidence suggests that in High Expressed Emotion (EE) families, family intervention is a possible effective intervention. We suggest caution in families with Low EE as one study suggests that in Low EE families, family intervention can increase the levels of EE.

Permanent knee sensorimotor system changes following ACL injury and surgery

The cruciate ligaments are components of the knee capsuloligamentous system providing vital neurosensory and biomechanical function. Since most historical primary ACL repair attempts were unsuccessful, reconstruction has become the preferred surgery. However, an increased understanding of the efficacy of lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet-rich plasma and stem cells has prompted reconsideration of what was once believed to be impossible. A growing number of in vivo animal studies and prospective clinical studies are providing increasing support for this intervention. The significance of ACL repair rather than reconstruction is that it more likely preserves the native neurosensory system, entheses, and ACL footprints. Tissue preservation combined with restored biomechanical function increases the likelihood for premorbid neuromuscular control system and dynamic knee stability recovery. This recovery should increase the potential for more patients to safely return to sports at their desired intensity and frequency. This current concepts paper revisits cruciate ligament neurosensory and neurovascular anatomy from the perspective of knee capsuloligamentous system function. Peripheral and central nerve pathways and central cortical representation mapping are also discussed. Surgical restoration of a more physiologically sound knee joint may be essential to solving the osteoarthritis dilemma. Innovative rehabilitative strategies and outcome measurement methodologies using more holistic and clinically relevant measurements that closely link biomechanical and neurosensory characteristics of physiological ACL function are discussed. Greater consideration of task-specific patient physical function and psychobehavioral links should better delineate the true efficacy of all ACL surgical and non-surgical interventions. Level of evidence IV.

Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial

BACKGROUND

Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice.

AIMS

To determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention.

METHOD

In a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning.

RESULTS

Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142).

CONCLUSIONS

Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

BACKGROUND

Chronic suppurative otitis media (CSOM) causes ear discharge and impairs hearing.

OBJECTIVES

Assess topical antibiotics (excluding steroids) for treating chronically discharging ears with underlying eardrum perforations (CSOM).

SEARCH STRATEGY

The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 1, 2005), MEDLINE (January 1951 to March 2005), EMBASE (January 1974 to March 2005), LILACS (January 1982 to March 2005), AMED (1985 to March 2005), CINAHL (January 1982 to March 2005), OLDMEDLINE (January 1958 to December 1965), PREMEDLINE, metaRegister of Controlled Trials (mRCT), and article references.

SELECTION CRITERIA

Randomised controlled trials; any topical antibiotic without steroids, versus no drug treatment, aural toilet, topical antiseptics, or other topical antibiotics excluding steroids; participants with CSOM.

DATA COLLECTION AND ANALYSIS

One author assessed eligibility and quality, extracted data, entered data onto RevMan; two authors inputted where there was ambiguity. We contacted investigators for clarifications.

MAIN RESULTS

Fourteen trials (1,724 analysed participants or ears). CSOM definitions and severity varied; some included otitis externa, mastoid cavity infections and other diagnoses. Methodological quality varied; generally poorly reported, follow-up usually short, handling of bilateral disease inconsistent. Topical quinolone antibiotics were better than no drug treatment at clearing discharge at one week: relative risk (RR) was 0.45 (95% confidence interval (CI) 0.34 to 0.59) (two trials, N = 197). No statistically significant difference was found between quinolone and non-quinolone antibiotics (without steroids) at weeks one or three: pooled RR were 0.89 (95% CI 0.59 to 1.32) (three trials, N = 402), and 0.97 (0.54 to 1.72) (two trials, N = 77), respectively. A positive trend in favour of quinolones seen at two weeks was largely due to one trial and not significant after accounting for heterogeneity: pooled RR 0.65 (0.46 to 0.92) (four trials, N = 276) using the fixed-effect model, and 0.64 (95% CI 0.35 to 1.17) accounting for heterogeneity with the random-effects model. Topical quinolones were significantly better at curing CSOM than antiseptics: RR 0.52 (95% CI 0.41 to 0.67) at one week (three trials, N = 263), and 0.58 (0.47 to 0.72) at two to four weeks (four trials, N = 519). Meanwhile, non-quinolone antibiotics (without steroids) compared to antiseptics were more mixed, changing over time (four trials, N = 254). Evidence regarding safety was generally weak.

AUTHORS' CONCLUSIONS

Topical quinolone antibiotics can clear aural discharge better than no drug treatment or topical antiseptics; non-quinolone antibiotic effects (without steroids) versus no drug or antiseptics are less clear. Studies were also inconclusive regarding any differences between quinolone and non-quinolone antibiotics, although indirect comparisons suggest a benefit of topical quinolones cannot be ruled out. Further trials should clarify non-quinolone antibiotic effects, assess longer-term outcomes (for resolution, healing, hearing, or complications) and include further safety assessments, particularly to clarify the risks of ototoxicity and whether quinolones may result in fewer adverse events than other topical treatments.

The Thorn nurse training initiative

An innovative comprehensive diploma course has been devised for mental health nurses who are providing care for those suffering from serious mental illness. The course addresses the devolution of long term hospital care and is primarily clinically based. This article describes the background to the research carried out and recognises the importance of the course's development in the light of recent government legislation. In addition, it identifies how and why this innovative nurse training is now being disseminated to mental health nurses and highlights the importance of introducing this model of clinical work into routine community practice.

The effects of family work training on mental health nurses' attitude to and knowledge of schizophrenia: a replication

The association between expressed emotion and the outcome of schizophrenia is well established, and the efficacy of family work for schizophrenia has been demonstrated. Mental health nurses are an expanding group in mental health service provision but their training does not include family work. Although there is some evidence that training mental health nurses in schizophrenia family work increases their knowledge of, and changes their attitudes towards schizophrenia, very little research has been conducted in this area. This paper replicates a previous study, and investigates whether mental health nurses can change their attitude and beliefs, and increase their knowledge about schizophrenia. Knowledge increased and attitudes changed during the initial period (3 months), and the gains were maintained throughout the 9-month course. However, in order to incorporate the skills learnt into their routine practice, mental health nurses will continue to need ongoing recognition, support, and enthusiasm from colleagues and managers.

Artemether-lumefantrine (six-dose regimen) for treating uncomplicated falciparum malaria

BACKGROUND

The World Health Organization recommends artemether-lumefantrine for treating uncomplicated malaria. We sought evidence of superiority of the six-dose regimen over existing treatment regimens as well as its effectiveness in clinical situations.

OBJECTIVES

To evaluate the six-dose regimen of artemether-lumefantrine for treating uncomplicated falciparum malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (April 2005), CENTRAL (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to April 2005), EMBASE (1974 to April 2005), LILACS (1982 to April 2005), conference proceedings, and reference lists of articles. We also contacted experts in malaria research and the pharmaceutical company that manufactures artemether-lumefantrine.

SELECTION CRITERIA

Randomized controlled trials comparing six doses of artemether-lumefantrine administered orally with standard treatment regimens (single drug or combination), or supervised with unsupervised treatment, for uncomplicated falciparum malaria.

DATA COLLECTION AND ANALYSIS

Two authors independently applied inclusion criteria to potentially relevant trials, assessed trial quality, and extracted data, including adverse events. Total failure by day 28 (day 42 for sulfadoxine-pyrimethamine and day 63 for mefloquine) was the primary outcome.

MAIN RESULTS

Nine trials (4547 participants) tested the six-dose regimen. Total failure at day 28 for artemether-lumefantrine was lower when compared with amodiaquine (270 participants, 1 trial), amodiaquine plus sulfadoxine-pyrimethamine (507 participants, 1 trial), but not with chloroquine plus sulfadoxine-pyrimethamine (201 participants, 2 trials). In comparisons with artemisinin derivative combinations, artemether-lumefantrine performed better than amodiaquine plus artesunate (668 participants, 2 trials), worse than mefloquine plus artesunate (270 participants, 4 trials), and no differently to dihydroartemisinin-napthoquine-trimethoprim (89 participants, 1 trial).

AUTHORS' CONCLUSIONS

The six-dose regimen of artemether-lumefantrine appears more effective than antimalarial regimens not containing artemisinin derivatives.

A meta-analysis of individual patient responses to lamotrigine or carbamazepine monotherapy

OBJECTIVE

To compare the effects of carbamazepine and lamotrigine monotherapy for people with partial onset seizures or generalized onset tonic-clonic seizures.

METHODS

A systematic review and meta-analysis using data on individual patients from randomized trials comparing lamotrigine with carbamazepine monotherapy. The review draws on the search strategy developed for the Cochrane Epilepsy Group, which searches MEDLINE and the Cochrane Controlled Trials register, and hand searches relevant journals. The outcomes considered were time to antiepileptic drug withdrawal, which would usually be for either inadequate seizure control or unacceptable adverse effects, time to first seizure, and 6-month remission.

RESULTS

Five randomized trials were identified containing data for 1,384 participants. Time to treatment withdrawal significantly improved with lamotrigine compared to carbamazepine (hazard ratio 0.55, 95% CI 0.35 to 0.84, random effects), while time to first seizure (hazard ratio 1.14, 95% CI 0.92 to 1.43, fixed effects) and seizure freedom at 6 months (relative risk 0.92, 95% CI 0.81 to 1.04, fixed effects) favor carbamazepine although the results are not significant.

CONCLUSIONS

Lamotrigine is significantly less likely to be withdrawn than carbamazepine, but results for time to first seizure suggest a nonsignificant trend that carbamazepine may be superior in terms of seizure control. Trials were of too short a duration to measure clinically important efficacy outcomes such as time to 12-month remission. Current industry-sponsored trials fail to adequately inform clinical practice and further more clinically relevant trials are needed in which longer-term outcomes are assessed before the place of lamotrigine in the treatment of epilepsy is defined.

Albendazole for lymphatic filariasis

BACKGROUND

Mass treatment with albendazole co-administered with another antifilarial drug is part of a global programme to eliminate lymphatic filariasis. We sought reliable evidence of the effects of albendazole on the disease and the parasite.

OBJECTIVES

To summarize the effects of albendazole alone or in combination with antifilarial drugs for clinical treatment and community control of lymphatic filariasis.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (August 2005), CENTRAL (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to August 2005), EMBASE (1974 to August 2005), LILACS (1982 to August 2005), and reference lists. We also contacted researchers, the World Health Organization, and GlaxoSmithKline.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of albendazole alone or combined with another antifilarial drug for treating individuals with lymphatic filariasis, or for reducing transmission in endemic communities.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility and trial quality, and extracted data. Authors contacted investigators for missing information or clarification.

MAIN RESULTS

Seven trials including 6997 participants (995 with detectable microfilariae) met the criteria. A comparison of albendazole and placebo detected no effect on microfilariae prevalence (920 participants; 3 trials); one trial (499 participants) reported significantly lower microfilariae density at six months. Albendazole performed slightly worse than ivermectin in two trials (436 participants). Compared with diethylcarbamazine (DEC), two small trials (56 participants) found little difference in microfilariae prevalence over an extended follow up. One larger trial (502 participants) found a statistically significant effect for DEC at six months, but none at three months. Microfilariae prevalence and density were statistically significantly lower with the combination of albendazole and ivermectin compared with ivermectin alone in two of three trials (649 participants). Two trials compared albendazole plus DEC with DEC alone and found no statistically significant difference in microfilariae prevalence, though one trial favoured the combination at six months (relative risk 0.62, 95% confidence interval 0.32 to 1.21; 491 participants). This trial also found a statistically significant reduction in microfilariae density.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confirm or refute that albendazole co-administered with DEC or ivermectin is more effective than DEC or ivermectin alone in clearing microfilariae or killing adult worms. Albendazole combined with ivermectin appears to have a small effect on microfilaraemia, but this was not consistently demonstrated. The effect of albendazole against adult and larval filarial parasites, alone and in combination with other antifilarial drugs, deserves further rigorous research.