Topical and device-based treatments for fungal infections of the toenails

BACKGROUND

Onychomycosis refers to fungal infections of the nail apparatus that may cause pain, discomfort, and disfigurement. This is an update of a Cochrane Review published in 2007; a substantial amount of new research warrants a review exclusively on toenails.

OBJECTIVES

To assess the clinical and mycological effects of topical drugs and device-based therapies for toenail onychomycosis.

SEARCH METHODS

We searched the following databases up to May 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers, and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials of topical and device-based therapies for onychomycosis in participants with toenail onychomycosis, confirmed by positive cultures, direct microscopy, or histological nail examination. Eligible comparators were placebo, vehicle, no treatment, or an active topical or device-based treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were complete cure rate (normal-looking nail plus fungus elimination, determined with laboratory methods) and number of participants reporting treatment-related adverse events.

MAIN RESULTS

We included 56 studies (12,501 participants, average age: 27 to 68 years), with mainly mild-to-moderate onychomycosis without matrix involvement (where reported). Participants had more than one toenail affected. Most studies lasted 48 to 52 weeks; 23% reported disease duration (variable). Thirty-five studies specifically examined dermatophyte-caused onychomycosis. Forty-three studies were carried out in outpatient settings. Most studies assessed topical treatments, 9% devices, and 11% both. We rated three studies at low risk of bias across all domains. The most common high-risk domain was performance bias. We present results for key comparisons, where treatment duration was 36 or 48 weeks, and clinical outcomes were measured at 40 to 52 weeks. Based on two studies (460 participants), compared with vehicle, ciclopirox 8% lacquer may be more effective in achieving complete cure (risk ratio (RR) 9.29, 95% confidence interval (CI) 1.72 to 50.14; low-quality evidence) and is probably more effective in achieving mycological cure (RR 3.15, 95% CI 1.93 to 5.12; moderate-quality evidence). Ciclopirox lacquer may lead to increased adverse events, commonly application reactions, rashes, and nail alteration (e.g. colour, shape). However, the 95% CI indicates that ciclopirox lacquer may actually make little or no difference (RR 1.61, 95% CI 0.89 to 2.92; low-quality evidence). Efinaconazole 10% solution is more effective than vehicle in achieving complete cure (RR 3.54, 95% CI 2.24 to 5.60; 3 studies, 1716 participants) and clinical cure (RR 3.07, 95% CI 2.08 to 4.53; 2 studies, 1655 participants) (both high-quality evidence) and is probably more effective in achieving mycological cure (RR 2.31, 95% CI 1.08 to 4.94; 3 studies, 1716 participants; moderate-quality evidence). Risk of adverse events (such as dermatitis and vesicles) was slightly higher with efinaconazole (RR 1.10, 95% CI 1.01 to 1.20; 3 studies, 1701 participants; high-quality evidence). No other key comparison measured clinical cure. Based on two studies, compared with vehicle, tavaborole 5% solution is probably more effective in achieving complete cure (RR 7.40, 95% CI 2.71 to 20.24; 1198 participants), but probably has a higher risk of adverse events (application site reactions were most commonly reported) (RR 3.82, 95% CI 1.65 to 8.85; 1186 participants (both moderate-quality evidence)). Tavaborole improves mycological cure (RR 3.40, 95% CI 2.34 to 4.93; 1198 participants; high-quality evidence). Moderate-quality evidence from two studies (490 participants) indicates that P-3051 (ciclopirox 8% hydrolacquer) is probably more effective than the comparators ciclopirox 8% lacquer or amorolfine 5% in achieving complete cure (RR 2.43, 95% CI 1.32 to 4.48), but there is probably little or no difference between the treatments in achieving mycological cure (RR 1.08, 95% CI 0.85 to 1.37). We found no difference in the risk of adverse events (RR 0.60, 95% CI 0.19 to 1.92; 2 studies, 487 participants; low-quality evidence). The most common events were erythema, rash, and burning. Three studies (112 participants) compared 1064-nm Nd:YAG laser to no treatment or sham treatment. We are uncertain if there is a difference in adverse events (very low-quality evidence) (two studies; 85 participants). There may be little or no difference in mycological cure at 52 weeks (RR 1.04, 95% CI 0.59 to 1.85; 2 studies, 85 participants; low-quality evidence). Complete cure was not measured. One study (293 participants) compared luliconazole 5% solution to vehicle. We are uncertain whether luliconazole leads to higher rates of complete cure (very low-quality evidence). Low-quality evidence indicates there may be little or no difference in adverse events (RR 1.02, 95% CI 0.90 to 1.16) and there may be increased mycological cure with luliconazole; however, the 95% CI indicates that luliconazole may make little or no difference to mycological cure (RR 1.39, 95% CI 0.98 to 1.97). Commonly-reported adverse events were dry skin, paronychia, eczema, and hyperkeratosis, which improved or resolved post-treatment.

AUTHORS' CONCLUSIONS

Assessing complete cure, high-quality evidence supports the effectiveness of efinaconazole, moderate-quality evidence supports P-3051 (ciclopirox 8% hydrolacquer) and tavaborole, and low-quality evidence supports ciclopirox 8% lacquer. We are uncertain whether luliconazole 5% solution leads to complete cure (very low-quality evidence); this outcome was not measured by the 1064-nm Nd:YAG laser comparison. Although evidence supports topical treatments, complete cure rates with topical treatments are relatively low. We are uncertain if 1064-nm Nd:YAG laser increases adverse events compared with no treatment or sham treatment (very low-quality evidence). Low-quality evidence indicates that there is no difference in adverse events between P-3051 (ciclopirox hydrolacquer), luliconazole 5% solution, and their comparators. Ciclopirox 8% lacquer may increase adverse events (low-quality evidence). High- to moderate-quality evidence suggests increased adverse events with efinaconazole 10% solution or tavaborole 5% solution. We downgraded evidence for heterogeneity, lack of blinding, and small sample sizes. There is uncertainty about the effectiveness of device-based treatments, which were under-represented; 80% of studies assessed topical treatments, but we were unable to evaluate all of the currently relevant topical treatments. Future studies of topical and device-based therapies should be blinded, with patient-centred outcomes and an adequate sample size. They should specify the causative organism and directly compare treatments.

Antithrombotic treatment after stroke due to intracerebral haemorrhage

BACKGROUND

Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of thromboembolism. Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of thromboembolism after ICH, but they may increase the risks of bleeding.

OBJECTIVES

To determine the overall effectiveness and safety of antithrombotic drugs for people with ICH.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (24 March 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2017, Issue 3), MEDLINE Ovid (from 1948 to March 2017), Embase Ovid (from 1980 to March 2017), and online registries of clinical trials (8 March 2017). We also screened the reference lists of included trials for additional, potentially relevant studies.

SELECTION CRITERIA

We selected all randomised controlled trials (RCTs) of any antithrombotic treatment after ICH.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We converted categorical estimates of effect to the risk ratio (RR) or odds ratio (OR), as appropriate. We divided our analyses into short- and long-term treatment, and used fixed-effect modelling for meta-analyses. Three review authors independently assessed the included RCTs for risks of bias and we created a 'Summary of findings' table using GRADE.

MAIN RESULTS

We included two RCTs with a total of 121 participants. Both RCTs were of short-term parenteral anticoagulation early after ICH: one tested heparin and the other enoxaparin. The risk of bias in the included RCTs was generally unclear or low, with the exception of blinding of participants and personnel, which was not done. The included RCTs did not report our chosen primary outcome (a composite outcome of all serious vascular events including ischaemic stroke, myocardial infarction, other major ischaemic event, ICH, major extracerebral haemorrhage, and vascular death). Parenteral anticoagulation did not cause a statistically significant difference in case fatality (RR 1.25, 95% confidence interval (CI) 0.38 to 4.07 in one RCT involving 46 participants, low-quality evidence), ICH, or major extracerebral haemorrhage (no detected events in one RCT involving 75 participants, low-quality evidence), growth of ICH (RR 1.64, 95% CI 0.51 to 5.29 in two RCTs involving 121 participants, low-quality evidence), deep vein thrombosis (RR 0.99, 95% CI 0.49 to 1.96 in two RCTs involving 121 participants, low quality evidence), or major ischaemic events (RR 0.54, 95% CI 0.23 to 1.28 in two RCTs involving 121 participants, low quality evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence from RCTs to support or discourage the use of antithrombotic treatment after ICH. RCTs comparing starting versus avoiding antiplatelet or anticoagulant drugs after ICH appear justified and are needed in clinical practice.

A randomised controlled trial of a blended learning education intervention for teaching evidence-based medicine

BACKGROUND

Few studies have been performed to inform how best to teach evidence-based medicine (EBM) to medical trainees. Current evidence can only conclude that any form of teaching increases EBM competency, but cannot distinguish which form of teaching is most effective at increasing student competency in EBM. This study compared the effectiveness of a blended learning (BL) versus didactic learning (DL) approach of teaching EBM to medical students with respect to competency, self-efficacy, attitudes and behaviour toward EBM.

METHODS

A mixed methods study consisting of a randomised controlled trial (RCT) and qualitative case study was performed with medical students undertaking their first clinical year of training in EBM. Students were randomly assigned to receive EBM teaching via either a BL approach or the incumbent DL approach. Competency in EBM was assessed using the Berlin questionnaire and the 'Assessing Competency in EBM' (ACE) tool. Students' self-efficacy, attitudes and behaviour was also assessed. A series of focus groups was also performed to contextualise the quantitative results.

RESULTS

A total of 147 students completed the RCT, and a further 29 students participated in six focus group discussions. Students who received the BL approach to teaching EBM had significantly higher scores in 5 out of 6 behaviour domains, 3 out of 4 attitude domains and 10 out of 14 self-efficacy domains. Competency in EBM did not differ significantly between students receiving the BL approach versus those receiving the DL approach [Mean Difference (MD)=-0.68, (95% CI-1.71, 0.34), p=0.19]. No significant difference was observed between sites (p=0.89) or by student type (p=0.58). Focus group discussions suggested a strong student preference for teaching using a BL approach, which integrates lectures, online learning and small group activities.

CONCLUSIONS

BL is no more effective than DL at increasing medical students' knowledge and skills in EBM, but was significantly more effective at increasing student attitudes toward EBM and self-reported use of EBM in clinical practice. Given the various learning styles preferred by students, a multifaceted approach (incorporating BL) may be best suited when teaching EBM to medical students. Further research on the cost-effectiveness of EBM teaching modalities is required.

Development and validation of the ACE tool: assessing medical trainees' competency in evidence based medicine

BACKGROUND

While a variety of instruments have been developed to assess knowledge and skills in evidence based medicine (EBM), few assess all aspects of EBM - including knowledge, skills attitudes and behaviour - or have been psychometrically evaluated. The aim of this study was to develop and validate an instrument that evaluates medical trainees' competency in EBM across knowledge, skills and attitude.

METHODS

The 'Assessing Competency in EBM' (ACE) tool was developed by the authors, with content and face validity assessed by expert opinion. A cross-sectional sample of 342 medical trainees representing 'novice', 'intermediate' and 'advanced' EBM trainees were recruited to complete the ACE tool. Construct validity, item difficulty, internal reliability and item discrimination were analysed.

RESULTS

We recruited 98 EBM-novice, 108 EBM-intermediate and 136 EBM-advanced participants. A statistically significant difference in the total ACE score was observed and corresponded to the level of training: on a 0-15-point test, the mean ACE scores were 8.6 for EBM-novice; 9.5 for EBM-intermediate; and 10.4 for EBM-advanced (p < 0.0001). Individual item discrimination was excellent (Item Discrimination Index ranging from 0.37 to 0.84), with internal reliability consistent across all but three items (Item Total Correlations were all positive ranging from 0.14 to 0.20).

CONCLUSION

The 15-item ACE tool is a reliable and valid instrument to assess medical trainees' competency in EBM. The ACE tool provides a novel assessment that measures user performance across the four main steps of EBM. To provide a complete suite of instruments to assess EBM competency across various patient scenarios, future refinement of the ACE instrument should include further scenarios across harm, diagnosis and prognosis.

Implementation of a blended learning approach to teaching evidence based practice: a protocol for a mixed methods study

BACKGROUND

Evidence based practice (EBP) requires that health professionals are competent in integrating the best evidence in their decision making. Being 'evidence-based' requires skills and knowledge in epidemiology, biostatistics and information literacy. EBP is commonly taught in medical and health sciences degrees, yet there is little evidence to guide educators as to the best teaching modality to increase learner competency in EBP.

METHODS/DESIGN

This study is mixed methods in design. A randomised controlled trial will examine the effectiveness of blended learning versus didactic approach of teaching EBP to medical students. The primary outcome of the RCT is EBP competency as assessed by the Berlin tool. Focus groups will be conducted to explore student perceptions and attitudes towards implementing a blended learning approach in teaching EBP. A concurrent triangulation design will be implemented, permitting quantitative data to inform the effectiveness of the intervention and qualitative data to contextualise the results.

DISCUSSION

This study will provide novel evidence on the effectiveness of blended learning in teaching EBP to a cohort of undergraduate and graduate-entry medical students.

Adopting a blended learning approach to teaching evidence based medicine: a mixed methods study

BACKGROUND

Evidence Based Medicine (EBM) is a core unit delivered across many medical schools. Few studies have investigated the most effective method of teaching a course in EBM to medical students. The objective of this study was to identify whether a blended-learning approach to teaching EBM is more effective a didactic-based approach at increasing medical student competency in EBM.

METHODS

A mixed-methods study was conducted consisting of a controlled trial and focus groups with second year graduate medical students. Students received the EBM course delivered using either a didactic approach (DID) to learning EBM or a blended-learning approach (BL). Student competency in EBM was assessed using the Berlin tool and a criterion-based assessment task, with student perceptions on the interventions assessed qualitatively.

RESULTS

A total of 61 students (85.9%) participated in the study. Competency in EBM did not differ between the groups when assessed using the Berlin tool (p = 0.29). Students using the BL approach performed significantly better in one of the criterion-based assessment tasks (p = 0.01) and reported significantly higher self-perceived competence in critical appraisal skills. Qualitative analysis identified that students had a preference for the EBM course to be delivered using the BL approach.

CONCLUSIONS

Implementing a blended-learning approach to EBM teaching promotes greater student appreciation of EBM principles within the clinical setting. Integrating a variety of teaching modalities and approaches can increase student self-confidence and assist in bridging the gap between the theory and practice of EBM.

Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial

AIM

Botulinum toxin A (BoNT-A) combined with occupational therapy is effective in improving upper limb outcomes in children with unilateral cerebral palsy (CP). It is now essential to identify the most effective therapies following BoNT-A. Given the added burden for children and families, the aim of this study was to explore whether modified constraint-induced movement therapy (mCIMT) leads to sufficiently superior gains compared with bimanual occupational therapy (BOT) in young children with unilateral CP following BoNT-A injections.

METHOD

In this randomized, controlled, evaluator-blinded trial, 34 children (20 males, 14 females; mean age 3y, SD 1y 4mo, range 18mo-6y) with unilateral CP were randomized using concealed allocation to one of two 8-week interventions. The experimental group (n=17) received BoNT-A and mCIMT. The comparison group (n=17) received BoNT-A and BOT. Participants were recruited from a physical rehabilitation clinic and randomized between August 2003 and May 2009. Primary outcome was measured using the Assisting Hand Assessment at 3 months. Secondary outcomes were measured at 3 months and 6 months using the Quality of Upper Extremity Skills Test, the Pediatric Evaluation of Disability Inventory, Canadian Occupational Performance Measure, and the Goal Attainment Scale.

RESULTS

There were no clinically important differences between groups at baseline. Immediately following intervention, there was no evidence of a superior effect for BoNT-A + mCIMT as determined by the Assisting Hand Assessment (estimated mean difference [EMD] 0.81, upper 95% confidence limit 3.6; p=0.32) or secondary outcomes. However, both groups showed improvement over time (BoNT-A + mCIMT: EMD 2.7, 95% confidence interval [CI] 0.7-5.2; BONT-A + BOT: EMD 4.7, 95% CI 2.1-8.6). Follow-up at 6 months also demonstrated no superior effect for BoNT-A + mCIMT.

INTERPRETATION

Following upper limb injection of BoNT-A, there was no evidence that mCIMT, despite the significantly increased intensity of the home programme, produced a superior effect across a range of outcomes compared with a structured programme of BOT in young children with unilateral CP.

Interventions for actinic keratoses

BACKGROUND

Actinic keratoses are a skin disease caused by long-term sun exposure, and their lesions have the potential to develop into squamous cell carcinoma. Treatments for actinic keratoses are sought for cosmetic reasons, for the relief of associated symptoms, or for the prevention of skin cancer development. Detectable lesions are often associated with alteration of the surrounding skin (field) where subclinical lesions might be present. The interventions available for the treatment of actinic keratoses include individual lesion-based (e.g. cryotherapy) or field-directed (e.g. topical) treatments. These might vary in terms of efficacy, safety, and cosmetic outcomes.

OBJECTIVES

To assess the effects of topical, oral, mechanical, and chemical interventions for actinic keratosis.

SEARCH METHODS

We searched the following databases up to March 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), and LILACS (from 1982). We also searched trials registers, conference proceedings, and grey literature sources.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the treatment of actinic keratoses with either placebo, vehicle, or another active therapy.

DATA COLLECTION AND ANALYSIS

At least two authors independently abstracted data, which included adverse events, and assessed the quality of evidence. We performed meta-analysis to calculate a weighted treatment effect across trials, and we expressed the results as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes (e.g. participant complete clearance rates), and mean difference (MD) and 95% CI for continuous outcomes (e.g. mean reduction in lesion counts).

MAIN RESULTS

We included 83 RCTs in this review, with a total of 10,036 participants. The RCTs covered 18 topical treatments, 1 oral treatment, 2 mechanical interventions, and 3 chemical interventions, including photodynamic therapy (PDT). Most of the studies lacked descriptions of some methodological details, such as the generation of the randomisation sequence or allocation concealment, and half of the studies had a high risk of reporting bias. Study comparison was difficult because of the multiple parameters used to report efficacy and safety outcomes, as well as statistical limitations. We found no data on the possible reduction of squamous cell carcinoma.The primary outcome 'participant complete clearance' significantly favoured four field-directed treatments compared to vehicle or placebo: 3% diclofenac in 2.5% hyaluronic acid (RR 2.46, 95% CI 1.66 to 3.66; 3 studies with 420 participants), 0.5% 5-fluorouracil (RR 8.86, 95% CI: 3.67 to 21.44; 3 studies with 522 participants), 5% imiquimod (RR 7.70, 95% CI 4.63 to 12.79; 9 studies with1871 participants), and 0.025% to 0.05% ingenol mebutate (RR 4.50, 95% CI 2.61 to 7.74; 2 studies with 456 participants).It also significantly favoured the treatment of individual lesions with photodynamic therapy (PDT) compared to placebo-PDT with the following photosensitisers: aminolevulinic acid (ALA) (blue light: RR 6.22, 95% CI 2.88 to 13.43; 1 study with 243 participants, aminolevulinic acid (ALA) (red light: RR 5.94, 95% CI 3.35 to 10.54; 3 studies with 422 participants), and methyl aminolevulinate (MAL) (red light: RR 4.46, 95% CI 3.17 to 6.28; 5 studies with 482 participants). ALA-PDT was also significantly favoured compared to cryotherapy (RR 1.31, 95% CI 1.05 to 1.64).The corresponding comparative risks in terms of number of participants completely cleared per 1000 were as follows: 313 with 3% diclofenac compared to 127 with 2.5% hyaluronic acid; 136 with 0.5% 5-fluorouracil compared to 15 with placebo; 371 with 5% imiquimod compared to 48 with placebo; 331 with ingenol mebutate compared to 73 with vehicle; 527 to 656 with ALA/MAL-PDT treatment compared to 89 to 147 for placebo-PDT; and 580 with ALA-PDT compared to 443 with cryotherapy.5% 5-fluorouracil efficacy was not compared to placebo, but it was comparable to 5% imiquimod (RR 1.85, 95% Cl 0.41 to 8.33).A significant number of participants withdrew because of adverse events with 144 participants affected out of 1000 taking 3% diclofenac in 2.5% hyaluronic acid, compared to 40 participants affected out of 1000 taking 2.5% hyaluronic acid alone, and 56 participants affected out of 1000 taking 5% imiquimod compared to 21 participants affected out of 1000 taking placebo.Based on investigator and participant evaluation, imiquimod treatment and photodynamic therapy resulted in better cosmetic outcomes than cryotherapy and 5-fluorouracil.

AUTHORS' CONCLUSIONS

For individual lesions, photodynamic therapy appears more effective and has a better cosmetic outcome than cryotherapy. For field-directed treatments, diclofenac, 5-fluorouracil, imiquimod, and ingenol mebutate had similar efficacy, but their associated adverse events and cosmetic outcomes are different. More direct comparisons between these treatments are needed to determine the best therapeutic approach.

Stress hyperglycemia may not be harmful in critically ill patients with sepsis

BACKGROUND

Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis.

METHODS

In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included.

RESULTS

Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock.

CONCLUSION

Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.

Lung diffusing capacity in adult bronchiectasis: a longitudinal study

BACKGROUND

Recent studies described a progressive decline in lung volumes in adult bronchiectasis. Interstitial lung disease is also a feature of bronchiectasis, but whether this is associated with a decline in lung diffusing capacity (measured as the diffusing capacity of the lung for carbon monoxide [D(LCO)]) is not well known.

OBJECTIVE

To assess longitudinal decline in diffusing capacity of the lung for carbon monoxide (D(LCO)) in adult bronchiectasis.

METHODS

Sixty-one subjects had a detailed baseline clinical and laboratory assessment, then were followed regularly with clinical and lung-function assessment for a median 7 years.

RESULTS

Baseline spirometry demonstrated mild obstructive lung disease, with a mean FEV(1) of 72% of predicted, mean forced vital capacity 87% of predicted, and normal D(LCO) (mean D(LCO) 88% of predicted, and mean D(LCO) adjusted for alveolar volume [D(LCO)/V(A)] 100% of predicted). There was an accelerated decline in D(LCO) and D(LCO)/V(A) over the 7-year period. The median D(LCO) decline was 2.9% of predicted per year (95% CI 2.3-4.1% of predicted per year). The median D(LCO)/V(A) decline was 2.4% of predicted per year (95% CI 2.1-4.0% of predicted per year). There was a significant relationship between D(LCO) decline and age and decline in FEV(1).

CONCLUSIONS

In our cohort of patients with bronchiectasis there was a progressive D(LCO) decline.

Community-based practice program in a rural medical school: benefits and challenges

BACKGROUND

Community-based education is a component of many medical curricula and may contribute to the solution of inequity in health services.

AIMS

This article evaluates a Community-based practice program (CBPP) conducted at Gippsland Medical School, Monash University. Students gain exposure to the community and conduct a community-based research project. The principal objective of the CBPP is to provide students with an opportunity to develop an interprofessional perspective on the application of social equity, justice and models of health interventions in the community.

METHODS

Students and representatives from community organisations (community educators) evaluated the CBPP using questionnaires, focus groups and interviews.

RESULTS

Students agree that participating in the CBPP improves understanding of community services, barriers and social determinants of health and the roles of health professionals. Community educators view the CBPP as a valuable platform for mutual learning for all parties involved, with students gaining real life experience. Challenges in the CBPP include formulating and conducting a research project and contextualisation of didactic material at community sites.

CONCLUSION

From this evaluation, based as it is on 1 year and limited data, we cannot unequivocally claim that the program fully meets its overall objective; however, there are positive outcomes and pointers to success.

Medical attribution of common mental disorders in a rural Indian population

Common mental disorders (CMD) refer to anxiety and depressive disorders causing significant disability and are commonly encountered in communities. Early diagnosis and treatment of these disorders can be improved if the population has a better understanding of them. This study aimed to explore the medical attribution of CMD among a rural community in South India using case vignettes. While most respondents agreed that there was a problem, they showed a preference for lay help over medical treatment. Improving awareness among rural communities of the usefulness of medical help for CMD might facilitate early diagnosis and treatment for these disorders.

Evaluation of mobile learning: students' experiences in a new rural-based medical school

BACKGROUND

Mobile learning (ML) is an emerging educational method with success dependent on many factors including the ML device, physical infrastructure and user characteristics. At Gippsland Medical School (GMS), students are given a laptop at the commencement of their four-year degree. We evaluated the educational impact of the ML program from students' perspectives.

METHODS

Questionnaires and individual interviews explored students' experiences of ML. All students were invited to complete questionnaires. Convenience sampling was used for interviews. Quantitative data was entered to SPSS 17.0 and descriptive statistics computed. Free text comments from questionnaires and transcriptions of interviews were thematically analysed.

RESULTS

Fifty students completed the questionnaire (response rate 88%). Six students participated in interviews. More than half the students owned a laptop prior to commencing studies, would recommend the laptop and took the laptop to GMS daily. Modal daily use of laptops was four hours. Most frequent use was for access to the internet and email while the most frequently used applications were Microsoft Word and PowerPoint. Students appreciated the laptops for several reasons. The reduced financial burden was valued. Students were largely satisfied with the laptop specifications. Design elements of teaching spaces limited functionality. Although students valued aspects of the virtual learning environment (VLE), they also made many suggestions for improvement.

CONCLUSIONS

Students reported many educational benefits from school provision of laptops. In particular, the quick and easy access to electronic educational resources as and when they were needed. Improved design of physical facilities would enhance laptop use together with a more logical layout of the VLE, new computer-based resources and activities promoting interaction.

Depressive disorders among adolescents managed in a child and adolescent mental health service

OBJECTIVE

The aims were to describe the prevalence and treatment of depressive disorders among case-managed adolescents attending a regional Child and Adolescent Mental Health Service (CAMHS).

METHOD

An observational study was conducted in a regional CAMHS over a 3-month period. Clinicians recorded treatment of their case-managed adolescents aged 12-18 years at the end of each calendar month. The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) and Children's Global Assessment Scale (CGAS) were collected at the beginning of the study period or at entry into the service, and repeated at discharge from the service or at the conclusion of the study period. Adolescents also completed the Reynold's Adolescent Depression Scale, 2nd edition.

RESULTS

Depressive disorders were the most common clinician diagnosis reported (22%). There was no statistically significant difference in treatment for depressed compared to non-depressed adolescents. There was a statistically significant improvement in both the HoNOSCA scores (p <0.001) and CGAS scores (p <0.001) for the whole sample.

CONCLUSION

Treatment appeared to be the same in type for depressed compared to non-depressed adolescents case managed within CAMHS.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE)

BACKGROUND

Cerebral palsy (CP) is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbance that occurred in the developing fetal or infant brain" (Rosenbaum 2007, p.9). The spastic motor type is the most common form of CP. Therapeutic management may include splinting/casting, passive stretching, facilitation of posture/movement, spasticity-reducing medication and surgery. Botulinum toxin-A (BoNT-A) is now used as an adjunct to these techniques in an attempt to reduce spasticity, improve range of movement and function.

OBJECTIVES

To assess the effectiveness of injections of BoNT-A or BoNT-A and occupational therapy in the treatment of the upper limb in children with CP.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register/CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (1966 to August Week 1 2008), EMBASE (1980 to 2008 Week 28) and CINAHL (1982 to August Week 1 2008).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing BoNT-A injection or BoNT-A injection and occupational therapy in the upper limb(s) with other types of treatment (including no treatment or placebo) in children with CP.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity and rated for quality using the PEDro scale. Data were extracted and entered into RevMan 5.0.15.

MAIN RESULTS

Ten trials met the inclusion criteria. PEDro quality ratings ranged from 6/10 to 10/10. Concentration of BoNT-A ranged from 50U/1.0ml to 200U/1.0ml saline with doses of 0.5U to 16U/kg body weight and total doses of 220 to 410 Units (Botox(R)).A combination of BoNT-A and occupational therapy is more effective than occupational therapy alone in reducing impairment, improving activity level outcomes and goal achievement, but not for improving quality of life or perceived self-competence. When compared with placebo or no treatment, there is moderate evidence that BoNT-A alone is not effective.

AUTHORS' CONCLUSIONS

This systematic review found high level evidence supporting the use of BoNT-A as an adjunct to managing the upper limb in children with spastic CP. BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy.Further research is essential to identify children most likely to respond to BoNT-A injections, monitor longitudinal outcomes, determine timing and effect of repeated injections and the most effective dosage, dilution and volume schedules. The most effective adjunct therapies including frequency and intensity of delivery also requires investigation.

T-cell cytokine profiles are altered in childhood asthma exacerbation

BACKGROUND AND OBJECTIVE

Stable asthma is characterized by the production of Th2 cytokines, although Th1 cytokines may play a key role in aspects such as airway hyper-responsiveness. This study explored cytokine profiles associated with asthma exacerbation.

METHODS

Intracellular T-cell cytokine production was measured in 16 children with acute severe asthma (emergency department), after convalescence (6 weeks, n = 13), with stable disease (after 6 months, n = 7) and in 14 age-matched hospital controls. Flow cytometry was used to identify CD4+ and CD8+ cells and to quantify intracellular T-cell production of the cytokines interferon (IFN)-gamma, IL-4 and IL-13. Cytokine production was compared using analysis of variance and random-effects generalized linear models and associations were examined using Pearson's correlation.

RESULTS

Cytokine production was evident in CD4+ and CD8+ cells, and compared with asthmatic children, non-asthmatics had a higher percentage of IFN-gamma+CD4+ cells (P = 0.01). The percentage of CD8+IFN-gamma+ cells was increased in the convalescent phase compared with acute (P = 0.009) and stable asthma (P = 0.004). IL-4+ cells were not significantly altered. IL-13 levels were higher in acute disease than in stable asthma (P = 0.009 in CD4+ cells) and IFN-gamma/IL-13 ratios indicated a Th2 profile during exacerbation (P = 0.005 in CD4+ cells).

CONCLUSIONS

IL-13, rather than IL-4, may play a pro-inflammatory role during acute severe asthma, whereas IFN-gamma responses were associated with recovery from acute severe asthma. These results suggest that altered T-cell cytokine profiles may contribute to the pathogenesis of and recovery from asthma exacerbations.

Interventions for pemphigus vulgaris and pemphigus foliaceus

BACKGROUND

A range of interventions have been described for treatment of pemphigus, however the optimal therapeutic strategy has not been established.

OBJECTIVES

To assess the efficacy and safety of all interventions used in the management of pemphigus vulgaris and pemphigus foliaceus.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (October 2008), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2008), MEDLINE (2003 to October 2008), EMBASE (2005 to October 2008), LILACS (1981 to October 2008), Ongoing Trials Registers, reference lists of articles, conference proceedings from international pemphigus meetings and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of any intervention in pemphigus vulgaris or pemphigus foliaceus.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed quality and extracted data from studies. All investigators were contacted for further information. Adverse events were identified from included studies.

MAIN RESULTS

Eleven studies with a total of 404 participants (337 pemphigus vulgaris, 27 pemphigus foliaceus and 40 not specified ) were identified. The quality of included studies was not high, the majority of studies did not report allocation concealment, and power was limited by very small sample sizes. Interventions assessed included prednisolone dose regimen, pulsed dexamethasone, azathioprine, cyclophosphamide, cyclosporine, dapsone, mycophenolate, plasma exchange, topical epidermal growth factor and traditional Chinese medicine. Ten studies included participants with newly diagnosed or newly active recurrent disease, and one trial included participants in maintenance phase.There was sufficient data for 4 meta-analyses, each pooling results of two studies only. For the majority of interventions, results were inconclusive. We found some interventions to be superior for certain outcomes, although we were unable to conclude which treatments are superior overall. Mycophenolate was more effective in achieving disease control than azathioprine (1 study; n=40; RR 0.72; 95% CI 0.52 to 0.99, NNT 3.7). There was evidence of a steroid-sparing benefit of azathioprine (1 study; n=57; MWD -3919 mg prednisolone; 95% CI -6712 to -1126) and cyclophosphamide (1 study; n=54; MWD -3355 mg prednisolone; 95% CI -6144 to -566) compared to glucocorticoids alone. Topical epidermal growth factor decreased time to control (1 study; n=20; HR 2.35; 95% CI 1.62 to 3.41).

AUTHORS' CONCLUSIONS

There is inadequate information available at present to ascertain the optimal therapy for pemphigus vulgaris or pemphigus foliaceus. Further research is required, especially to assess the optimal glucocorticoid dose, the role of adjuvant immunosuppressive medications, and long-term adverse events to improve harm:benefit analyses.

Microbiologic follow-up study in adult bronchiectasis

There is minimal published longitudinal data about pathogenic microorganisms in adults with bronchiectasis. Therefore a study was undertaken to assess the microbiologic profile over time in bronchiectasis. A prospective study of clinical and microbiologic outcomes was performed. Subjects were assessed by a respiratory physician and sputum sample were collected for analysis. Subjects were followed up and had repeat assessment performed. Eighty-nine subjects were followed up for a period of 5.7+/-3.6 years. On initial assessment the two most common pathogens isolated were Haemophilus influenzae (47%) and Pseudomonas aeruginosa (12%) whilst 21% had no pathogens isolated. On follow-up review results were similar (40% H. influenzae, 18% P. aeruginosa and 26% no pathogens). The prevalence of antibiotic resistance of isolates increased from 13% to 30%. Analysis of a series of H. influenzae isolates showed they were nearly all nontypeable and all were different subtypes. Subjects with no pathogens isolated from their sputum had the mildest disease, while subjects with P. aeruginosa had the most severe bronchiectasis. Many subjects with bronchiectasis are colonized with the same bacterium over an average follow-up of 5 years. Different pathogens are associated with different patterns of clinical disease.

National Breast Cancer Audit: ductal carcinoma in situ management in Australia and New Zealand

BACKGROUND

Ductal carcinoma in situ (DCIS) is a significant issue in Australia and New Zealand with rising incidence because of the implementation of mammographic screening. Current information on its natural history is unable to accurately predict progression to invasive cancer. In 2003, the National Breast Cancer Centre in Australia published recommendations for DCIS. In Australia and New Zealand, the National Breast Cancer Audit collects information on DCIS cases. This article will examine these recommendations and provide information from the audit on current DCIS management.

METHODS

Three thousand six hundred and twenty-nine cases of DCIS were entered by 274 breast surgeons between January 1998 and December 2004. Data items in the National Breast Cancer Audit database that were covered in the National Breast Cancer Centre recommendations were reviewed. Information was available on the following: diagnostic biopsy rates for all cases and mammographically positive cases and rates of breast conserving surgery (BCS), clear margins following BCS, postoperative radiotherapy following BCS for groups at high risk of recurrence as well as axillary procedures and tamoxifen prescription.

RESULTS

Close adherence was found in diagnostic biopsy, BCS and clear margin rates. Some high-risk groups received radiotherapy, although women with 'close' margins did not in 33% of cases. Axillary procedures were conducted in 23% of cases and most (81%) patients were not prescribed tamoxifen.

CONCLUSION

There was predominantly close adherence to recommendations with three possible areas of improvement: fewer axillary procedures, an appraisal of radiotherapy practice following BCS and more investigation into tamoxifen prescription practices for DCIS.

Outcome in adult bronchiectasis

The outcome in adult bronchiectasis has not been well described; in particular there has been a lack of long-term prospective studies. Therefore a follow-up study was performed to assess outcome in bronchiectasis in a cohort of adult patients. One hundred-and-one sequential adults, 33 male and 68 female; age 54 +/- 14 years (mean +/- SD) with bronchiectasis had a clinical assessment and spirometry performed. All were non-smokers and 84 were classified as having idiopathic disease. Patients were commenced on a standardized treatment regime and followed up for a minimum period of 2 years. On their last review when patients were clinically stable, a repeat clinical assessment and spirometry was performed and compared with the initial review. The primary endpoints measured were symptoms and FEV1. Subjects were followed up for 8.0 +/- 4.9 years. Clinical review showed that the patients had persistent symptoms that, in the case of dyspnea and sputum volume, were worse on follow-up. Spirometry showed a significant decline in FEV1 over the follow-up period with an average loss of 49 ml per year. This study showed in this group of predominantly female adult patients with bronchiectasis followed up for 8 years, patients had persistent symptoms and an excess loss in FEV1.

NATIONAL BREAST CANCER AUDIT: OVERVIEW OF INVASIVE BREAST CANCER MANAGEMENT

BACKGROUND

The National Breast Cancer Audit is an initiative of the Breast Section of the Royal Australasian College of Surgeons collecting surgical information in early breast cancer. It is managed in conjunction with the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical. An overview of results for invasive breast cancer from January 1999 until December 2004 is presented to provide preliminary data for participating surgeons.

METHODS

Invasive breast cancer cases were retrieved from the National Breast Cancer Audit database for the 274 participating breast surgeons in Australia and New Zealand. Data for a variety of clinical parameters were analysed to provide an overview of the diagnostic, histological, surgical and adjuvant therapy management issues.

RESULTS

There were 25,026 cases of invasive breast cancer. Annual percentages of mammographically detected cancers from 1999 to 2004 did not differ significantly. Breast-conserving surgery rates also remained stable at 60%. Margins were involved in 5% of patients; an additional 9% had final margins of less than 1 mm. Radiotherapy followed breast-conserving surgery in most cases (86%). Patients undergoing mastectomy with large tumours (>5 cm) underwent radiotherapy in 71% of cases. When at least four lymph nodes were positive, radiotherapy followed mastectomy in the majority (75%) of cases. The most frequently carried out axillary procedure was a level 2 dissection. Chemotherapy was received by 78% of oestrogen receptor negative, axillary node positive, postmenopausal patients. Tamoxifen was used in the majority (83%) of oestrogen receptor positive cases.

CONCLUSION

Surgeons contributing their invasive breast cancer data show a high quality of treatment. Some further improvement may be possibly related to excision margins and tamoxifen prescription for oestrogen receptor negative cancers. Chemotherapy prescription might also warrant further investigation.

Autologous cartilage implantation for full thickness articular cartilage defects of the knee

BACKGROUND

Treatments for managing articular cartilage defects of the knee, including drilling and abrasion arthroplasty, are not always effective. When they are, long-term benefits may not be maintained and osteoarthritis may develop, resulting in the need for a total knee replacement. An alternative is the surgical implantation of healthy cartilage cells into damaged areas (autologous cartilage implantation).

OBJECTIVES

To determine the effectiveness of autologous cartilage implantation (ACI) in people with full thickness articular cartilage defects of the knee.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (15 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2005), MEDLINE (1966 to December 2005), CINAHL (1982 to December Week 2, 2004), EMBASE (1988 to 2005 Week 50), SPORTDiscus (1830 to January 2005) and the National Research Register Issue 3, 2005.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing ACI with any other type of treatment (including no treatment or placebo) for symptomatic cartilage defects of the medial or lateral femoral condyle, femoral trochlea or patella.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion independently. We assessed study quality based on adequacy of the randomisation process, adequacy of the allocation concealment process, potential for selection bias after allocation and level of masking. Data was not pooled due to clinical and methodological heterogeneity in the studies.

MAIN RESULTS

We included four randomised controlled trials (266 participants). One trial of ACI versus mosaicplasty reported statistically significant results for ACI at one year, but only in a post-hoc subgroup analysis of participants with medial condylar defects; 88% had excellent or good results with ACI versus 69% with mosaicplasty. A second trial of ACI versus mosaicplasty found no statistically significant difference in clinical outcomes at two years. There was no statistically significant difference in outcomes at two years in a trial comparing ACI with microfracture. In addition, one trial of matrix-guided ACI versus microfracture did not contain enough long-term results to reach definitive conclusions.

AUTHORS' CONCLUSIONS

The use of ACI and other chondral resurfacing techniques is becoming increasingly widespread. However, there is at present no evidence of significant difference between ACI and other interventions. Additional good quality randomised controlled trials with long-term functional outcomes are required.

Characterisation of the onset and presenting clinical features of adult bronchiectasis

BACKGROUND

There is little information available on the features of initial presentation of bronchiectasis and documentation of the onset and progress of symptoms leading up to this. Therefore a study was performed on a large cohort of adult patients presenting to Monash Medical Centre (MMC) to survey the course of their disease up to the time of diagnosis.

OBJECTIVES

To characterise the onset and presenting clinical features of bronchiectasis in adults.

METHODS

A cross-sectional study of 103 adults presenting to a tertiary referral hospital with newly diagnosed bronchiectasis. Clinical features of bronchiectasis and results of spirometry, sputum microbiology and radiology were assessed and correlated.

RESULTS

Most patients had idiopathic bronchiectasis (74%) and did not have other significant disease. The dominant symptom was chronic productive cough present in 98% of patients with other important symptoms being chronic rhinosinusitis (70%), dyspnoea (62%), and fatigue (74%). Most patients had had a chronic productive cough for over 30 years prior to diagnosis and over 80% of patients had chronic respiratory symptoms from childhood. The dominant finding on physical examination was the presence of crackles which were generally bi-basal. Spirometry showed mild airway obstruction with an average forced expiratory volume in 1s of the cohort of 76% predicted. Radiologic imaging generally showed multilobar disease (80%).

CONCLUSIONS

The typical profile of bronchiectasis in this group of patients was of longstanding productive cough, rhinosinusitis and fatigue in non-smokers with crackles on chest auscultation.

Risk factors for intensive care in children with acute asthma

OBJECTIVE

A retrospective case-control study at Monash Medical Centre (MMC), a tertiary referral hospital in Melbourne, Australia, was conducted to identify risk factors associated with very severe asthma in paediatric patients.

METHODOLOGY

Asthmatics admitted to an intensive care unit (ICU; n=52) were identified and considered to represent cases of very severe/near fatal asthma (NFA group). This group was compared to asthmatics who had been admitted on one occasion only to the emergency department at MMC (non-NFA controls, n=53). Patient files were examined and factors that may be linked to NFA were recorded. Information not on file was obtained from patients/parents during a structured telephone interview. Data for the two groups were compared, univariate and multivariate logistic regression analyses were performed, and odds ratios (OR) were calculated.

RESULTS

Univariate analysis indicated that asthmatics with NFA were more likely to be older (P=0.01) and have a longer duration of asthma (P=0.02). They were also more likely to have hay fever (P=0.002; OR, 7.6), use inhaled corticosteroids (P=0.001), long acting beta(2) agonists (P=0.02), have an asthma management plan (P=0.006), and see a respiratory specialist (P=0.001). Parental smoking habits were not different between the groups. Multivariate logistic regression analysis identified male gender (P=0.05; OR, 5.7) and use of inhaled corticosteroids (P=0.07; OR, 7.2) as factors that may be predictive of NFA.

CONCLUSIONS

This study identifies a number of factors associated with NFA; many are similar to those reported in adult patients. Asthma severity explains some findings, but the data also suggest that additional independent risk factors such as gender and duration of asthma may operate in children.

The Australasian Triage Scale: Examining emergency department nurses' performance using computer and paper scenarios

STUDY OBJECTIVE

The purpose of this study is to examine emergency nurses' performance using triage scenarios characterized by type of patient population (adult versus pediatric) and mode of delivery (paper versus computer).

METHODS

A combination of paper-based (script alone) and computer-based (script plus still photographs) triage scenarios were used. Of the 28 scenarios used, half were written and half were computer based. Within each subgroup, there were 7 adult and 7 pediatric scenarios. Participants were asked to allocate an Australasian Triage Scale category for each triage scenario.

RESULTS

One hundred sixty-seven participants completed a total of 2,349 adult scenarios, and 161 participants completed 2,265 pediatric scenarios. Sixty-one percent of the triage decisions made by the nurses were "expected" triage decisions, 18% were "undertriage," decisions, and 21% were "overtriage" decisions. Nurse triage allocation decisions for the scenarios containing still photographs delivered by computer demonstrated a higher average agreement percentage of 66.2% (kappa=0.56; tau b =0.77; P <.0001) compared with the average agreement percentage of 55.4% (kappa=0.42; tau b =0.75; P <.0001) using paper-based (text-only) scenarios.

CONCLUSION

The mode of delivery appeared to have an effect on the nurses' triage performance. It is unclear whether the use of simple still photographs used in the computer mode of delivery resulted in a higher incidence of expected triage decisions and, thus, improved performance. The use of cues such as photographs and video footage to enhance the fidelity of triage scenarios may be useful not only for the education of triage nurses but also the conduct of research into triage decisionmaking. However, further exploration and research in this area are warranted.

Hyperbaric oxygen therapy for thermal burns

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than 1 atmosphere in a pressure vessel. This technology has been used to treat a variety of disease states and has been described as helping patients who have sustained burns.

OBJECTIVES

The aim of this review was to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of thermal burns.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (Ovid 1966 to November Week 2, 2003), CINAHL (Ovid 1982 to December Week 2 2003), EMBASE (Ovid 1980 to September 2003), DORCTHIM (Database of Randomised Controlled Trials in Hyperbaric Medicine) from inception to 2003, and reference lists of articles.

SELECTION CRITERIA

We included all randomised controlled trials that compared the effect of HBOT with no HBOT (no treatment or sham).

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. Data was extracted and entered into RevMan 4.2.3.

MAIN RESULTS

Four randomised controlled trials were identified, of which two satisfied the inclusion criteria. The trials were of poor methodological quality. As a result, it was difficult to have confidence in the individual results and it would not have been appropriate to attempt to pool the data. One trial reported no difference in length of stay, mortality, or number of surgeries between the control and HBO-treated groups once these variables were adjusted for the patient's condition. The second trial reported mean healing times that were shorter in patients exposed to HBOT (mean: 19.7 days versus 43.8 days).

REVIEWERS' CONCLUSIONS

This systematic review has not found sufficient evidence to support or refute the effectiveness of HBOT for the management of thermal burns. Evidence from the two randomised controlled trials is insufficient to provide clear guidelines for practice. Further research is needed to better define the role of HBOT in the treatment of thermal burns.

Randomized, placebo-controlled trial of intramuscular vitamin B12for the treatment of hyperhomocysteinaemia in dialysis patients

BACKGROUND

Plasma homocysteine is elevated in patients with end-stage renal disease (ESRD) and is a risk factor for cardiovascular disease. Folic acid has been shown to partially reduce homocysteine levels in dialysis patients. It is not known whether vitamin B12 reduces homocysteine independent of folic acid in patients who are not vitamin B12 deficient.

AIM

To determine whether 1 mg vitamin B12 lowers homocysteine in stable, chronic, haemodialysis patients independent of folic acid.

METHODS

Twenty-eight haemodialysis patients were randomized to receive three doses of 1 mg vitamin B12 or 1 mL saline placebo in a double-blind fashion at 1-month intervals. Fasting plasma total homocysteine, folic acid, red-cell folate, vitamin B12 and haemoglobin levels were determined prior to each dose and 4 weeks after the final injection. The study was powered to detect a 30% reduction in homocysteine over the 3 months.

RESULTS

Both the two groups were well matched with respect to total homocysteine levels, folic acid, red-cell folate and vitamin B12 levels. Serum vitamin B12 levels were significantly higher in the treatment group compared to placebo (217.7 pmol/L; 95% confidence interval (CI) 103.0-332.5; P < 0.001) at the end of the trial but homocysteine levels were not significantly different (3.08 micromol/L; 95% CI -4.44-10.61; P= 0.406).

CONCLUSIONS

The administration of intramuscular vitamin B12 over a 3-month period does not result in any reduction of plasma homocysteine levels in haemo-dialysis patients independent of folate status, however reductions of <30% cannot be excluded by the present study. High-dose folic acid remains the treatment of choice in reducing homocysteine, but whether this results in a reduction in cardiovascular events remains to be determined.

Spatial Association and Distribution of Beet necrotic yellow vein virus and Beet soilborne mosaic virus in Sugar Beet Fields

Beet necrotic yellow vein virus (BNYVV) causes rhizomania of sugar beet (Beta vulgaris), which is characterized by stunting, leaf necrosis, constriction of the taproot, and extensive lateral- and feeder-root proliferation. Beet soilborne mosaic virus (BSBMV) causes similar but typically less severe symptoms than those of BNYVV. Both viruses are widely distributed in sugar beet-growing regions of the United States. Both viruses are vectored by the soilborne plasmodiophorid Polymyxa betae Keskin and are very similar in morphology and biology, sharing many characteristics in common. In 1999, soil samples were collected from sugar beet fields in Colorado, Minnesota, North Dakota, and Texas to determine the spatial association and covariation of the viruses in sugar beet fields. In 2000, additional samples were collected from fields in Minnesota and North Dakota. Over the 2-year period, soil samples were collected from 11 fields in various quadrat sizes. The viruses were assayed by growing sugar beet (cv. Beta 1395) in the soil samples and their incidence was determined using the double-antibody sandwich enzyme-linked immunosorbent assay. Both viruses were detected in samples from all fields but were in greater frequencies singly than in association. Association of the two viruses (where both viruses were detected in the same sample or bait plant) varied among fields, ranging from 1 to 42%. Geostatistical analysis revealed that both viruses, in large part, exhibited similar spatial patterns. In all but two fields, there was no spatial dependence among the sampling locations at sampled grid sizes. Their semivariances were constant at all separation distances in all directions indicating random spatial patterns. Overall, the spatial pattern of BNYVV appeared to be a little more structured than that of BSBMV. Even though both viruses are transmitted by the same vector and also exhibited similar distribution patterns, the incidence of one virus may not be estimated from that of the other due to lack of strong association and spatial dependence. However, similarity in spatial patterns of the two suggests that a similar sampling method can be employed for both viruses.

Autologous cartilage implantation for full thickness articular cartilage defects of the knee

BACKGROUND

A variety of strategies have been employed for managing articular cartilage defects of the knee, including drilling and abrasion arthroplasty. These treatments are not always effective and when they are, the benefits may only be transitory. Unsuccessfully treated cartilage damage may progress to degenerative disease states and result in the need for a total knee replacement. In recent years the surgical implantation of healthy cartilage cells (autologous cartilage implantation [ACI] ) into damaged areas has been seen as an alternative option and is currently under investigation as a potential improvement over the current strategies for the management and treatment of articular cartilage defects.

OBJECTIVES

To determine the effectiveness of ACI in patients with full thickness articular cartilage defects of the knee.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (May 2002), Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to June Week 4 2001), CINAHL (1982 to July Week 2 2001), EMBASE (1980 to 2001 Week 27), SPORTDiscus (1949 to June 2001), Current Contents (1993 Week 26 to 2001 Week 30) and the National Research Register (Issue 2, May 2002).

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing ACI with any other type of treatment (including no treatment or placebo) for symptomatic cartilage defects of the medial or lateral femoral condyle, trochlea or patella.

DATA COLLECTION AND ANALYSIS

Two independent reviewers applied the entry criteria to identified studies.

MAIN RESULTS

No completed randomised controlled trials investigating this treatment were identified through the above searches. One possible trial has been placed in Studies Awaiting Assessment, awaiting translation of the full trial report. Ongoing trials currently underway will be incorporated in future updates of this review.

REVIEWER'S CONCLUSIONS

No information is available from RCTs which can influence current practice. Therefore, since current evidence is subject to the inherent weaknesses of case series or reports, ACI must currently be considered as a technology under investigation whose effectiveness is yet to be determined in well designed and conducted clinical trials. The results of ongoing randomised clinical trials will help improve this situation.

Phylogenetic origins of the plant mitochondrion based on a comparative analysis of 5S ribosomal RNA sequences

The complete nucleotide sequences of 5S ribosomal RNAs from Rhodocyclus gelatinosa, Rhodobacter sphaeroides, and Pseudomonas cepacia were determined. Comparisons of these 5S RNA sequences show that rather than being phylogenetically related to one another, the two photosynthetic bacterial 5S RNA sequences show that rather than being phylogenetically related to one another, the two photosynthetic bacterial 5S RNAs share more sequence and signature homology with the RNAs of two nonphotosynthetic strains. Rhodobacter sphaeroides is specifically related to Paracoccus denitrificans and Rc. gelatinosa is related to Ps. cepacia. These results support earlier 16S ribosomal RNA studies and add two important groups to the 5S RNA data base. Unique 5S RNA structural features previously found in P. denitrificans are present also in the 5S RNA of Rb. sphaeroides; these provide the basis for subdivisional signatures. The immediate consequence of our obtaining these new sequences is that we are able to clarify the phylogenetic origins of the plant mitochondrion. In particular, we find a close phylogenetic relationship between the plant mitochondria and members of the alpha subdivision of the purple photosynthetic bacteria, namely, Rb. sphaeroides, P. denitrificans, and Rhodospirillum rubrum.

Identification of missing persons: the Spanish "Phoenix" program

In 1999, Spain was the first country to officially start a National Program to try to identify cadavers and human remains which could not be identified by the use of traditional forensic approaches. This attempt is called "Phoenix Program". Two independent mitochondrial DNA (mtDNA) databases were generated, which can automatically compare and match identical or similar sequences. One is the Reference Database, with mtDNA sequences from maternal relatives of missing persons, who provide the samples (buccal swabs) voluntarily; the other is the Questioned Database, comprised of mtDNA data of unknown remains and cadavers. Although the first phase of the program (typing of all unidentified human remains) will probably not be completed until December 2003, positive identifications are being made in the interim. To date, more than 1,200 families have contacted Phoenix, and at least 280 reference samples and 48 questioned evidences have been analyzed. When mtDNA matches are found, another independent analysis is performed as a part of the quality control mechanism. Once a match is confirmed (so far in 6 cases), an attempt is made to analyze short tandem repeat (STR) loci. We call for international collaboration to make this effort valuable worldwide.

Kawasaki Syndrome in an Adult: Case Report and Review of the Literature in Adolescents and Adults

Kawasaki syndrome in adults is very rare, with fewer than 50 cases reported in the English-language literature. We describe the case of a physician with Kawasaki syndrome and summarize the clinical features and treatment of 11 patients in the literature since the last review in 1994. Our patient presented with high fever, conjunctivitis, and arthralgias, then developed progressive toxicity with oral lesions, cervical adenopathy, and desquamation of the fingers and toes. No exanthematous rash or coronary artery aneurysms were found. Recovery was rapid after therapy with aspirin and intravenous immunoglobulin (IVIg). The diagnosis of Kawasaki syndrome depends on clinical criteria and the exclusion of other diseases. This diagnosis can be challenging to make in an adult, particularly when it presents without all typical features. Kawasaki syndrome must be considered nonetheless in an adult with unexplained fever of more than 5 days duration, because early diagnosis and combination therapy with aspirin and IVIg can prevent the life-threatening complication of coronary artery aneurysms.

Field conditions for agricultural workers in the El Paso, Texas region

Agricultural workers labor long hours under difficult conditions in many of the nations fields and orchards. Agricultural workers are primarily minority populations, the most dominant group being Hispanic/Latino. The Rural Coalition and the Environmental and Occupational Health Sciences Institute were funded under the National Institute of Environmental Health Sciences (NIEHS) Environmental Justice Program, to investigate health and environmental issues that impact agricultural workers along the Texas-Mexican border area. A Spanish-language field conditions survey was developed and distributed to the workers entering the Sin Fronteras Organizing Project in El Paso, Texas. There were 841 valid surveys collected and analyzed for the calendar year 1998. Workers age mean was 51, with 18.6 years of work experience in agriculture. In the time period surveyed, workers labored for 7.2 hours per day. The primary crop in which they worked were chilies. Of particular concern were issues concerning food, water, and hygiene. Almost all workers stated they had access to fresh drinking water (97 percent), 20 percent did not have access to food, and 30 percent were offered alcohol for purchase. Almost one-third of the workers did not have water available for hand washing in the field. Only 8 percent of the workers reported pesticides used in the fields in which they were working; this number is lower and may be a reflection of the improved training and caution taken by the workers. Clearly additional research in the area of field conditions and the impact and enforcement of state and federal regulation needs to be carried out.