Acupuncture for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS), a disorder of altered bowel habits associated with abdominal pain or discomfort. The pain, discomfort, and impairment from IBS often lead to healthcare medical consultation (Talley 1997) and workplace absenteeism, and associated economic costs (Leong 2003). A recent randomized controlled trial shows variable results but no clear evidence in support of acupuncture as an effective treatment for IBS (Fireman 2001).

OBJECTIVES

The objective of this systematic review is to determine whether acupuncture is more effective than no treatment, more effective than 'sham' (placebo) acupuncture, and as effective as other interventions used to treat irritable bowel syndrome. Adverse events associated with acupuncture were also assessed.

SEARCH STRATEGY

The following electronic bibliographic databases were searched irrespective of language, date of publication, and publication status: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, EMBASE, the Chinese Biomedical Database, the Cumulative Index to Nursing and Allied Health (CINAHL), and the Allied and Complementary Medicine Database (AMED). References in relevant reviews and RCTs were screened by hand. The last date for searching for studies was 7 February 2006.

SELECTION CRITERIA

Published reports of randomized controlled trials (RCTs) and quasi-randomised trials of acupuncture therapy for IBS.

DATA COLLECTION AND ANALYSIS

All eligible records identified were dually evaluated for eligibility and dually abstracted. Methodological quality was assessed using the Jadad scale and the Linde Internal Validity Scale. Data from individual trials were combined for meta-analysis when the interventions were sufficiently similar. Heterogeneity was assessed using the I squared statistic.

MAIN RESULTS

Six trials were included. The proportion of responders, as assessed by either the global symptom score or the patient-determined treatment success rate, did not show a significant difference between the acupuncture and the sham acupuncture group with a pooled relative risk of 1.28 (95% CI 0.83 to 1.98; n=109). Acupuncture treatment was also not significantly more effective than sham acupuncture for overall general well-being, individual symptoms (e.g., abdominal pain, defecation difficulties, diarrhea, and bloating), the number of improved patients assessed by blinded clinician, or the EuroQol score. For two of the studies without a sham control, acupuncture was more effective than control treatment for the improvement of symptoms: acupuncture versus herbal medication with a RR of 1.14(95% CI 1.00 to 1.31; n=132); acupuncture plus psychotherapy versus psychotherapy alone with a RR of 1.20 (95% CI 1.03 to 1.39; n=100). When the effect of ear acupuncture treatment was compared to an unclearly specified combination of one or more of the drugs diazepam, perphenazine or domperidone, the difference was not statistically significant with a RR of 1.49(95% CI 0.94 to 2.34; n=48).

AUTHORS' CONCLUSIONS

Most of the trials included in this review were of poor quality and were heterogeneous in terms of interventions, controls, and outcomes measured. With the exception of one outcome in common between two trials, data were not combined. Therefore, it is still inconclusive whether acupuncture is more effective than sham acupuncture or other interventions for treating IBS.

Surgery for nonarteritic anterior ischemic optic neuropathy

BACKGROUND

Nonarteritic ischemic optic neuropathy is characterized by sudden and painless loss of vision in the eye, accompanied by pallid swelling of the optic disc. No medical therapy has been proven effective in treating this condition.

OBJECTIVES

The objective of this review is to assess the safety and efficacy of surgery compared with other treatment or usual care in people with nonarteritic ischemic optic neuropathy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, in The Cochrane Library, MEDLINE, EMBASE and the UK National Research Register (NRR). The last search was on 13 July 2005.

SELECTION CRITERIA

We included randomized controlled trials.

DATA COLLECTION AND ANALYSIS

We obtained full copies of all potentially relevant articles. One randomized trial was eligible for inclusion. One author extracted data which was verified by another author. No synthesis was required.

MAIN RESULTS

The one included trial randomized 258 participants and was stopped early. At the time of the 24-month report the follow-up rate was 95.3% for six months and 67.4% for 24 months (174 participants, 89 careful follow up and 85 surgery). There was no evidence of a benefit of surgery on visual acuity. At six months 32.0% of the surgery group had improved visual acuity by three or more lines compared with 42.6% of the careful follow up group (unadjusted risk ratio (RR) 0.75, 95% confidence interval (CI) 0.54 to 1.04). At 24 months 29.4% of the surgery group had improved compared with 31.0% of the careful follow up group (unadjusted RR 0.95, 95% CI 0.60 to 1.49). Participants who underwent surgery had a greater risk of losing three or more lines of vision. At six months 18.9% in the surgery group had worsened compared with 14.8% in the careful follow up group (RR 1.28; 95% CI 0.73 to 2.24). At 24 months 20.0% in the surgery group had worsened compared with 21.8% in the careful follow up group (RR 0.92; 95% CI 0.51 to 1.64).

AUTHORS' CONCLUSIONS

Results from the single trial indicate no evidence of a beneficial effect of optic nerve decompression surgery for nonarteritic ischemic optic neuropathy.

Herbal medicines for treating HIV infection and AIDS

BACKGROUND

HIV-infected people and AIDS patients often seek complementary therapies including herbal medicines due to reasons such as unsatisfactory effects, high cost, non-availability, or adverse effects of conventional medicines.

OBJECTIVES

To assess beneficial effects and risks of herbal medicines in patients with HIV infection and AIDS.

SEARCH STRATEGY

Electronic searches included the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, Science Citation Index, the Chinese Biomedical Database, TCMLARS; plus CISCOM, AMED, and NAPRALERT; combined with manual searches. The search ended in December 2004.

SELECTION CRITERIA

Randomized clinical trials on herbal medicines compared with no intervention, placebo, or antiretroviral drugs in patients with HIV infection, HIV-related disease, or AIDS. The outcomes included mortality, HIV disease progression, new AIDS-defining event, CD4 cell counts, viral load, psychological status, quality of life, and adverse effects.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and assessed the methodological quality of trials according to randomization, allocation concealment, double blinding, and drop-out.

MAIN RESULTS

Nine randomized placebo-controlled trials involving 499 individuals with HIV infection and AIDS met the inclusion criteria. Methodological quality of trials was assessed as adequate in five full publications and unclear in other trials. Eight different herbal medicines were tested.A compound of Chinese herbs (IGM-1) showed significantly better effect than placebo in improvement of health-related quality of life in 30 symptomatic HIV-infected patients (WMD 0.66, 95% CI 0.05 to 1.27). IGM-1 appeared not to affect overall health perception, symptom severity, CD4 count, anxiety or depression (Burack 1996a). An herbal formulation of 35 Chinese herbs did not affect CD4 cell counts, viral load, AIDS events, symptoms, psychosocial measure, or quality of life (Weber 1999). There was no statistical difference between SPV30 and placebo in new AIDS-defining events, CD4 cell counts, or viral load (Durant 1998) although an earlier pilot trial showed positive effect of SPV30 on CD4 cell count (Durant 1997). Combined treatment of Chinese herbal compound SH and antiretroviral agents showed increased antiviral benefit compared with antiretrovirals alone (Sangkitporn 2004). SP-303 appeared to reduce stool weight (p = 0.008) and abnormal stool frequency (p = 0.04) in 51 patients with AIDS and diarrhoea (Holodniy 1999). Qiankunning appeared not to affect HIV-1 RNA levels (Shi 2003), Curcumin ineffective in reducing viral load or improving CD4 cell counts (Hellinger 1996), and Capsaicin ineffective in relieving pain associated with HIV-related peripheral neuropathy (Paice 2000). The occurrence of adverse effects was higher in the 35 Chinese herbs preparation (19/24) than in placebo (11/29) (79% versus 38%, p = 0.003) (Weber 1999). Qiankunning was associated with stomach discomfort and diarrhoea (Shi 2003).

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of herbal medicines in HIV-infected individuals and AIDS patients. Potential beneficial effects need to be confirmed in large, rigorous trials.

Medicinal herbs for hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection is a serious health problem world-wide. Medicinal herbs are increasingly being used for hepatitis C.

OBJECTIVES

To assess the efficacy and safety of medicinal herbs for hepatitis C virus infection.

SEARCH STRATEGY

Searches were applied to The Controlled Trial Registers of The Cochrane Hepato-Biliary Group, The Cochrane Complementary Medicine Field, and The Cochrane Library as well as MEDLINE, EMBASE, BIOSIS, Chinese and Japanese databases. Five Chinese journals and one Japanese journal were handsearched. No language restriction was used.

SELECTION CRITERIA

Randomised clinical trials comparing medicinal herbs (single herb or compound of herbs) versus placebo, no intervention, general non-specific treatment, other herbal medicine, or interferon and/or ribavirin treatment. Trials of medicinal herbs plus interferon and/or ribavirin versus interferon and/or ribavirin alone were also included. Trials could be double-blind, single-blind, or unblinded.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. The methodological quality of the trials was evaluated using the generation of allocation sequence, allocation concealment, double blinding, and the Jadad-scale. The outcomes were presented as relative risk or weighted mean difference, both with 95% confidence interval.

MAIN RESULTS

Ten randomised trials, including 517 patients with mainly chronic hepatitis C, evaluated ten different medicinal herbs versus various control interventions (four placebo, four interferon, two other herbs). The methodological quality was considered adequate in four trials and inadequate in six trials. Compared with placebo in four trials, none of the medicinal herbs showed positive effects on clearance of serum HCV RNA or anti-HCV antibody or on serum liver enzymes, except one short-term trial in which a silybin preparation showed a significant effect on reducing serum aspartate aminotransferase and gamma-glutamyltranspeptidase activities. The herbal compound Bing Gan Tang combined with interferon-alpha showed significantly better effects on clearance of serum HCV RNA (relative risk 2.54; 95% confidence interval 1.43 to 4.49) and on normalisation of serum alanine aminotransferase activity (relative risk 2.54; 95% confidence interval 1.43 to 4.49) than interferon-alpha monotherapy. The herbal compound Yi Zhu decoction showed a significant effect on clearance of serum HCV RNA and normalisation of ALT levels compared to glycyrrhizin plus ribavirin. Yi Er Gan Tang showed a significant effect on normalising serum alanine aminotransferase compared to silymarin plus glucurolactone. There was no significant efficacy of the other examined herbs. The herbs were associated with adverse events.

REVIEWER'S CONCLUSIONS

There is no firm evidence of efficacy of any medicinal herbs for HCV infection. Medicinal herbs for HCV infection should not be used outside randomised clinical trials.

Surgery for nonarteritic anterior ischemic optic neuropathy

BACKGROUND

Nonarteritic ischemic optic neuropathy is characterized by sudden and painless loss of vision in one eye, accompanied by pallid swelling of the optic disc. Although various medical interventions, such as corticosteroids and phenytoin sodium, have been used to treat nonarteritic ischemic optic neuropathy, no therapy has been proven effective.

OBJECTIVES

The objective of this review is to assess the safety and efficacy of surgical treatment compared with other treatment or usual care in people with nonarteritic ischemic optic neuropathy.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register - Central and MEDLINE. The most recent searches were performed in December 1997.

SELECTION CRITERIA

We included randomized trials comparing surgery to no surgery in people with nonarteritic ischemic optic neuropathy.

DATA COLLECTION AND ANALYSIS

We obtained full copies of all potentially relevant articles. Only one article described a randomized trial of surgery and it was eligible for inclusion. No formal assessment of quality was done. One reviewer extracted data. No synthesis was required, as there was only one trial.

MAIN RESULTS

The one trial identified randomized 258 patients. The only published report with outcomes data for that trial presents preliminary results from 244 patients who had achieved six months of follow-up at the time of the report. Participants assigned to surgery did no better than participants assigned to careful follow-up regarding improved visual acuity of three or more lines of vision at six months: 32.6% of the surgery group improved compared with 42.7% of the careful follow-up group. The adjusted odds ratio (OR), adjusted for baseline visual acuity and diabetes, comparing the two groups for three or more lines improvement was 0.74 (95% confidence interval (CI) 0.39 to 1. 38) (surgery group improvement was worse than careful follow-up). In addition, participants receiving surgery had a significantly greater risk of losing three or more lines of vision at six months: 23.9% in the surgery group worsened compared with 12.4% in the careful follow-up group. The six-month adjusted OR comparing the two groups for loss of three or more lines of vision was 1.96 (95% CI 0.87 to 4.41). Spontaneous improvement of three or more lines of vision was observed in 42.7% of participants in the careful follow-up group.

REVIEWER'S CONCLUSIONS

Results from the Ischemic Optic Neuropathy Decompression Trial indicate that optic nerve decompression surgery for nonarteritic ischemic optic neuropathy is not effective.

Frequency and correlates of adjustment disorder related to cardiac surgery in older patients

The diagnosis of adjustment disorder is a dilemma in older medically ill patients. The authors conducted a prospective study of older cardiac surgery patients. Semistructured interview techniques were used to distinguish emotional impairment from physical impairment to diagnose an adjustment disorder. Among 71 patients interviewed at three points in time, 50.7% had an adjustment disorder. At 6 months after surgery, 30.6% were still showing evidence of emotional functional impairment. Continued impairment was related to initial severity of depressive and anxiety symptoms. Implications and suggestions for future research are discussed.

The relationship of presenting physical complaints to depressive symptoms in primary care patients

OBJECTIVE

To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice.

DESIGN

A cross-sectional study that was part of a larger prevalence study of depression in primary care.

SETTING

A general medical primary care practice in a teaching medical center in rural New England.

PATIENTS

1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification.

INTERVENTIONS

None.

RESULTS

Complaints that discriminated between depressed and non-depressed patients (at the p = 0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%).

CONCLUSIONS

Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms.

Recognition of depression by internists in primary care: a comparison of internist and "gold standard" psychiatric assessments

In an effort to elucidate the process of internists' recognition of depression in primary care settings, a comparison of internist and "gold standard" psychiatric assessments of patients was undertaken in a rural primary care practice over a 15-month period. Clinical characteristics and diagnoses, global assessments of psychosocial stress, and two aspects of chief-complaint presentation style, clarity and somatization, were recorded by the internists for each patient, who was independently assessed by a psychiatrist for the presence of any specific depressive disorder by structured interview. Internists correctly labeled 57% of the interview-assessed depressives as depressed; 13% of patients with "no psychiatric disorder" were assessed as depressed by internists. Clinical and demographic characteristics of the "false-negative" and "false-positive" internists' diagnoses were examined to clarify how internists think of "depression" in the primary care context.