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McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014; 22:363-88. [PMID: 24462672 DOI: 10.1016/j.joca.2014.01.003] [Citation(s) in RCA: 1998] [Impact Index Per Article: 181.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/06/2014] [Accepted: 01/15/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide. METHOD Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores. RESULTS Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation). CONCLUSION These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.
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Practice Guideline |
11 |
1998 |
2
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Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 2019; 27:1578-1589. [PMID: 31278997 DOI: 10.1016/j.joca.2019.06.011] [Citation(s) in RCA: 1906] [Impact Index Per Article: 317.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 05/21/2019] [Accepted: 06/20/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. METHODS We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. RESULTS Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. CONCLUSION These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.
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Review |
6 |
1906 |
3
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Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Phys Ther 1993; 73:254-62; discussion 263-5. [PMID: 8456144 DOI: 10.1093/ptj/73.4.254] [Citation(s) in RCA: 196] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Loss of lower-extremity strength increases the risk of falls in older persons. The purpose of this study was to test the hypothesis that a vigorous program of lower-extremity strengthening, walking, and postural control exercises would improve the single-stance balance of healthy older women and lower their risk of falls and fall-associated injuries. SUBJECTS From a total of 38 respondents, 21 women were randomly assigned to either a treatment group (combined training, n = 12) or a control group (flexibility training, n = 9). The subjects ranged in age from 62 to 75 years (mean = 68, SD = 3.5). METHODS A randomized control trial compared the effects of two exercise programs on static balance. The combined training group exercised three times per week on knee extension and sitting leg press machines, walked briskly for 20 minutes, and performed postural control exercises, which included simple tai chi movements. The flexibility training group performed postural control exercises weekly. Measurements of balance were obtained on a force platform in double and single stance, at baseline and following 6 months of exercise training. RESULTS Double-stance measurements were unchanged after training. The mean displacement of the center of pressure in single stance improved 17% in the combined training group and did not change in the flexibility training group. A repeated-measures analysis of variance revealed that the difference in improvement between the combined training and flexibility training groups was not significant. DISCUSSION AND CONCLUSION This is the first intervention trial to demonstrate improvements in single-stance postural sway in older women with exercise training. Additional studies with more subjects will be needed to determine whether a combined training program of resistance training, walking, and postural exercises can improve balance more than a program of postural control exercises alone.
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Clinical Trial |
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196 |
4
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Carnes D, Parsons S, Ashby D, Breen A, Foster NE, Pincus T, Vogel S, Underwood M. Chronic musculoskeletal pain rarely presents in a single body site: results from a UK population study. Rheumatology (Oxford) 2007; 46:1168-70. [PMID: 17488750 DOI: 10.1093/rheumatology/kem118] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate the frequency and health impact of chronic multi-site musculoskeletal pain, in a representative UK sample. METHOD Population postal questionnaire survey, using 16 general practices in the southeast of England, nationally representative urban/rural, ethnic and socioeconomic mix. A random selection of 4049 registered patients, aged 18 or over, were sent a questionnaire. The main outcome measures were chronic pain location, identified using a pain drawing; distress, pain intensity and disability as measured by the GHQ12 and the Chronic Pain Grade. RESULTS A total of 2445 patients (60%) responded to the survey (44% male, mean age 52 yrs); 45% had chronic musculoskeletal pain. Of those with chronic pain, three quarters had pain in multiple sites (two or more sites). Variables significantly predicting this were: age under 55, [odds ratio (OR) 0.5, 95% confidence interval (CI) 0.4, 0.6]; psychological distress (OR 1.8, CI at 95% 1.4, 2.2) and high pain intensity (OR 5.2, CI at 95% 4.1, 6.7). Only 33% of multi-site pain distributions conformed to the American College of Rheumatology definition of chronic widespread pain. CONCLUSIONS Multi-site chronic pain is more common than single-site chronic pain and is commonly associated with other problems. Indiscriminate targeting of research and care for chronic musculoskeletal pain on single sites may often be inappropriate.
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18 |
180 |
5
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Field SK, Underwood M, Brant R, Cowie RL. Prevalence of gastroesophageal reflux symptoms in asthma. Chest 1996; 109:316-22. [PMID: 8620699 DOI: 10.1378/chest.109.2.316] [Citation(s) in RCA: 141] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
STUDY OBJECTIVE To determine the prevalences of symptomatic gastroesophageal reflux (GER), reflux-associated respiratory symptoms (RARS), and reflux-associated beta-agonist inhaler use in asthmatics. DESIGN Questionnaire-based, cross-sectional analytic survey. SETTING Outpatient asthma and clinical research clinics attached to the University of Calgary tertiary care centre and two family practices. PATIENTS Asthma group consisted of 109 patients referred to an outpatient asthma clinic. First control group consisted of 68 patients visiting their family physicians. Second control group consisted of 67 patients with thyroid disease, hypercholesterolemia, or diabetes participating in drug trials. RESULTS Among the asthmatics, 77%, 55%, and 24% experienced heartburn, regurgitation, and swallowing difficulties, respectively. Symptoms were less prevalent in the control groups. At least one antireflux medication was required by 37% of asthmatics (p < 0.001, vs controls). None of the asthma medications were associated with an increased likelihood of symptomatic GER. In the week prior to completing the questionnaire, 41% of the asthmatics noted RARS, including cough, dyspnea, and wheeze and 28% used their inhalers while experiencing GER symptoms. Inhaler use correlated with the severity of heartburn (r = 0.28, p < 0.05) and regurgitation (r = 0.40, p < 0.05) CONCLUSIONS The questionnaire demonstrated a greater prevalence of GER symptoms, RARS, and reflux-associated inhaler use in asthmatics. This excessive inhaler use may explain how GER indirectly causes asthma to worsen.
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29 |
141 |
6
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Lamb SE, Lall R, Hansen Z, Castelnuovo E, Withers EJ, Nichols V, Griffiths F, Potter R, Szczepura A, Underwood M, BeST trial group. A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technol Assess 2010; 14:1-253, iii-iv. [PMID: 20807469 DOI: 10.3310/hta14410] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Collaborators] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To estimate the clinical effectiveness of active management (AM) in general practice versus AM plus a group-based, professionally led cognitive behavioural approach (CBA) for subacute and chronic low back pain (LBP) and to measure the cost of each strategy over a period of 12 months and estimate cost-effectiveness. DESIGN Pragmatic multicentred randomised controlled trial with investigator-blinded assessment of outcomes. SETTING Fifty-six general practices from seven English regions. PARTICIPANTS People with subacute and chronic LBP who were experiencing symptoms that were at least moderately troublesome. INTERVENTIONS Participants were randomised (in a ratio of 2:1) to receive either AM+CBA or AM alone. MAIN OUTCOME MEASURES Primary outcomes were the Roland Morris Disability Questionnaire (RMQ) and the Modified Von Korff Scale (MVK), which measure LBP and disability. Secondary outcomes included mental and physical health-related quality of life (Short Form 12-item health survey), health status, fear avoidance beliefs and pain self-efficacy. Cost-utility of CBA was considered from both the UK NHS perspective and a broader health-care perspective, including both NHS costs and costs of privately purchased goods and services related to LBP. Quality-adjusted life-years (QALYs) were calculated from the five-item EuroQoL. RESULTS Between April 2005 and April 2007, 701 participants were randomised: 233 to AM and 468 to AM+CBA. Of these, 420 were female. The mean age of participants was 54 years and mean baseline RMQ was 8.7. Outcome data were obtained for 85% of participants at 12 months. Benefits were seen across a range of outcome measures in favour of CBA with no evidence of group or therapist effects. CBA resulted in at least twice as much improvement as AM. Mean additional improvement in the CBA arm was 1.1 [95% confidence interval (CI) 0.4 to 1.7], 1.4 (95% CI 0.7 to 2.1) and 1.3 (95% CI 0.6 to 2.1) change points in the RMQ at 3, 6 and 12 months respectively. Additional improvement in MVK pain was 6.8 (95% CI 3.5 to 10.2), 8.0 (95% CI 4.3 to 11.7) and 7.0 (95% CI 3.2 to 10.7) points, and in MVK disability was 4.3 (95% CI 0.4 to 8.2), 8.1 (95% CI 4.1 to 12.0) and 8.4 (95% CI 4.4 to 12.4) points at 3, 6 and 12 months respectively. At 12 months, 60% of the AM+CBA arm and 31% of the AM arm reported some or complete recovery. Mean cost of attending a CBA course was 187 pounds per participant with an additional benefit in QALYs of 0.099 and an additional cost of 178.06 pounds. Incremental cost-effectiveness ratio was 1786.00 pounds. Probability of CBA being cost-effective reached 90% at about 3000 pounds and remained at that level or above; at a cost-effectiveness threshold of 20,000 pounds the CBA group had an almost 100% probability of being considered cost-effective. User perspectives on the acceptability of group treatments were sought through semi-structured interviews. Most were familiar with key messages of AM; most who had attended any group sessions had retained key messages from the sessions and two-thirds talked about a reduction in fear avoidance and changes in their behaviour. Group sessions appeared to provide reassurance, lessen isolation and enable participants to learn strategies from each other. CONCLUSIONS Long-term effectiveness and cost-effectiveness of CBA in treating subacute and chronic LBP was shown, making this intervention attractive to patients, clinicians and purchasers. Short-term (3-month) clinical effects were similar to those found in high-quality studies of other therapies and benefits were maintained and increased over the long term (12 months). Cost per QALY was about half that of competing interventions for LBP and because the intervention can be delivered by existing NHS staff following brief training, the back skills training programme could be implemented within the NHS with relative ease. TRIAL REGISTRATION Current Controlled Trials ISRCTN37807450. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Collaborators
Sallie Lamb, Martin Underwood, Zara Hansen, Liset Pengel, Gill Foster, Emma Withers, Margaret Vickers, Louise Letley, Anita Chauhan, Susie Carpenter, Rachel Potter, Ranjit Lall, Anne Daykin, Sarah Stewart-Brown, Cath Sackley, Roy Jones, Chris McCarthy, Julie Barlow, Tamar Pincus, Stephen Joseph, Robert Hills, Gary Macfarlane, Paul Watson, Emma Withers, Lisa Craven, Sophie Page, Ranjit Lall, Emanuela Castelnuovo, Ala Szczepura, Mike Clark, Judy Briant, Valerie Brueton, John Coult, Sue Counsell, Alison Dearson, Julia Edwards, Anne Hall, Lesley Hand, Zara Hansen, Katie Holt, Kate Horsler, Christine Jarvey, Sandra Jepson, Andy Law, Louise Letley, Janet Lowe, Pat Marsh, Medlock Dymphna, Jo-Anne Miles, Olivia Neeley, Vivien Nichols, Tracey O'Brien, Mary Ogden, Grace Pearn, Rachel Potter, Emma Rayfield, Simon Rowland, Judy Rushmer, Nicola Sloan, Barbara Stewart, Sam Thompson, Rachel Turnbull, Gill Walker, Sue Webb, Anna Williams, Mark Woolvine,
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Multicenter Study |
15 |
109 |
7
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Parsons S, Breen A, Foster NE, Letley L, Pincus T, Vogel S, Underwood M. Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations. Fam Pract 2007; 24:308-16. [PMID: 17602173 DOI: 10.1093/fampra/cmm027] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic pain has large health care costs and a major impact on the health of those affected. Few studies have also considered the severity of pain in different parts of the body across all age groups. OBJECTIVES To measure the prevalence and troublesomeness of musculoskeletal pain in different body locations and age groups, in a consistent manner, without using location specific health outcome measures. METHODS A cross-sectional postal survey of 4049 adults registered with 16 MRC General Practice Research Framework practices. Frequency of chronic pain overall and troublesome pain by location and age was calculated. Logistic regression was undertaken to explore the relationship between chronic pain and demographic factors. RESULTS We received 2504 replies; response rate 60%. The prevalence of chronic pain was 41%. The prevalence of chronic pain rose from 23% in 18-24 year olds reaching a peak of 50% in 55-64 year olds. Troublesome pain over the last 4 weeks was commonest in the lower back (25%), neck (18%), knee (17%) and shoulder (17%). Troublesome wrist, elbow, shoulder, neck and lower back pain were most prevalent in the 45- to 64-year-age groups. Troublesome hip/thigh, knee and ankle/foot pain were most prevalent in those aged 75 or more. CONCLUSIONS Great efforts have been made to develop and test treatments for low back pain. Our findings suggest that the overall prevalence of troublesome neck, knee and shoulder pain approaches that of troublesome low back pain and that similar efforts may be required to improve the management these pains.
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18 |
104 |
8
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Bull JH, Ellison G, Patel A, Muir G, Walker M, Underwood M, Khan F, Paskins L. Identification of potential diagnostic markers of prostate cancer and prostatic intraepithelial neoplasia using cDNA microarray. Br J Cancer 2001; 84:1512-9. [PMID: 11384102 PMCID: PMC2363654 DOI: 10.1054/bjoc.2001.1816] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The identification of novel genes or groups of genes expressed in prostate cancer may allow earlier diagnosis or more accurate staging of the disease. We describe the assembly and use of a 1877-member microarray representing cDNA clones from a range of prostate cancer stages and grades, precursor lesions and normal tissue. Using labelled cDNA from tumour samples obtained from TURP or radical prostatectomy, analysis of expression patterns identified many up-regulated transcripts. Cell lines were found to over-express fewer genes than diseased tissue samples. 17 known genes were found to over-express more than 4-fold in 4 or more cancers out of 15 cancers. Only 2 genes were over-expressed in 6 out of 15 cancers or more, whilst no genes were consistently found to be over-expressed in all cancer samples. Novel prostate cancer associations for several well characterized genes or full length cDNAs were identified, including PLRP1, JM27, human UbcM2, dynein light intermediate chain 2 and human homologue of rat sec61. Novel associations with high-grade PIN include: breast carcinoma fatty acid synthase and cDNA DKFZp434B0335. We shortlist and discuss the most significant over-expressed genes in prostate cancer and PIN, and highlight expression differences between malignant and benign samples.
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research-article |
24 |
87 |
9
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Underwood M, Arbyn M, Parry-Smith W, De Bellis-Ayres S, Todd R, Redman CWE, Moss EL. Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis. BJOG 2012; 119:1293-301. [DOI: 10.1111/j.1471-0528.2012.03444.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13 |
76 |
10
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Shaffer D, Garland A, Vieland V, Underwood M, Busner C. The impact of curriculum-based suicide prevention programs for teenagers. J Am Acad Child Adolesc Psychiatry 1991; 30:588-96. [PMID: 1890092 DOI: 10.1097/00004583-199107000-00010] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The impact of three school-based suicide prevention programs was assessed by comparing attitudes and knowledge of 758 9th and 10th graders with those of 680 control pupils, matched on age, ethnicity, and socioeconomic status at the school level, who did not receive the programs. Evaluations were conducted before exposure to the programs and again 1 month later. A large majority of students knew and subscribed to some of the more important program goals before exposure to the program. There was little evidence of program impact among the minority that did not. Most students were interested by the programs, and positive reactions were more common among female and minority students.
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34 |
73 |
11
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Dunn SV, Lawson D, Robertson S, Underwood M, Clark R, Valentine T, Walker N, Wilson-Row C, Crowder K, Herewane D. The development of competency standards for specialist critical care nurses. J Adv Nurs 2000; 31:339-46. [PMID: 10672091 DOI: 10.1046/j.1365-2648.2000.01292.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In defining the contemporary role of the specialist nurse it is necessary to challenge the concept of nursing as merely a combination of skills and knowledge. Nursing must be demonstrated and defined in the context of client care and include the broader notions of professional development and competence. This qualitative study sought to identify the competency standards for nurse specialists in critical care and to articulate the differences between entry-to-practice standards and the advanced practice of specialist nurses. Over 800 hours of specialist critical care nursing practice were observed and grouped into 'domains' or major themes of specialist practice using a constant comparison qualitative technique. These domains were further refined to describe attributes of the registered nurses which resulted in effective and/or superior performance (competency standards) and to provide examples of performance (performance criteria) which met the defined standard. Constant comparison of the emerging domains, competency standards and performance criteria to observations of specialist critical care practice, ensured the results provided a true reflection of the specialist nursing role. Data analysis resulted in 20 competency standards grouped into six domains: professional practice, reflective practice, enabling, clinical problem solving, teamwork, and leadership. Each of these domains is comprised of between two and seven competency standards. Each standard is further divided into component parts or 'elements' and the elements are illustrated with performance criteria. The competency standards are currently being used in several Australian critical care educational programmes and are the foundation for an emerging critical care credentialling process. They have been viewed with interest by a variety of non-critical care specialty groups and may form a common precursor from which further specialist nursing practice assessment will evolve.
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25 |
66 |
12
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Anderson ME, Underwood M, Bridges RJ, Meister A. Glutathione metabolism at the blood-cerebrospinal fluid barrier. FASEB J 1989; 3:2527-31. [PMID: 2572501 DOI: 10.1096/fasebj.3.13.2572501] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Glutathione metabolism and transport in the choroid plexus were probed by determining the effects of administration to rats of several compounds (buthionine sulfoximine, L-2-oxothiazolidine-4-carboxylate, L-(alpha 5,5S)-alpha-amino-3-chloro-4,5-dihydro-5-isoxazole acetic acid, gamma-glutamyl alanine, and glutathione monoethyl ester) on the levels of glutathione and cysteine in the cerebrospinal fluid. The findings indicate that glutathione is actively metabolized in the choroid plexus by pathways similar to those in kidney and other tissues. The level of glutathione in the cerebrospinal fluid can be decreased or increased by giving compounds that do not, under similar conditions, appreciably alter total brain levels of glutathione. Glutathione monoethyl ester is effectively transported into the cerebrospinal fluid.
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36 |
60 |
13
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Lee D, Underwood M, Mason D, Shkarin A, Hoch S, Harris J. Multimode optomechanical dynamics in a cavity with avoided crossings. Nat Commun 2015; 6:6232. [DOI: 10.1038/ncomms7232] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/07/2015] [Indexed: 11/09/2022] Open
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10 |
56 |
14
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Sutaria S, Katbamna R, Underwood M. Effectiveness of interventions for the treatment of acute and prevention of recurrent gout--a systematic review. Rheumatology (Oxford) 2006; 45:1422-31. [PMID: 16632483 DOI: 10.1093/rheumatology/kel071] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine the evidence for the effectiveness of treatments for acute gout and the prevention of recurrent gout. METHOD Seven electronic databases were searched for randomized controlled trials of treatments for gout from their inception to the end of 2004. No language restrictions were applied. All randomized controlled trials of treatments routinely available for the treatment of gout were included. Trials of the prevention of recurrence were included only if patients who had had gout and had at least 6 months of follow-up were studied. RESULTS We found 13 randomized controlled trials of treatment for acute gout, two of which were placebo controlled. Colchicine was found to be effective in one study; however, the entire colchicine group developed toxicity. The only robust conclusion from studies of non-steroidal anti-inflammatory drugs is that pain relief from indometacin and etoricoxib are equivalent. We found one randomized controlled trial, reported only as a conference abstract, of recurrent gout prevention. CONCLUSION The shortage of robust data to inform the management of a common problem such as gout is surprising. All of the drugs used to treat gout can have serious side effects. The incidence of gout is highest in the elderly population. It is in this group, who are at a high risk of serious adverse events, that we are using drugs of known toxicity. The balance of risks and benefits for the drug treatment of gout needs to be reassessed.
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Systematic Review |
19 |
51 |
15
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Underwood M. The older driver. Clinical assessment and injury prevention. ARCHIVES OF INTERNAL MEDICINE 1992; 152:735-40. [PMID: 1558430 DOI: 10.1001/archinte.152.4.735] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Continued increases in the number of older drivers during the next several decades will increase the importance of medical, ethical, and health policy issues related to driving privileges. Physicians have a critical role in examining patients for driving competence and in screening for impairments that increase the risk of motor vehicle injuries. Both age-related and disease-related factors may affect driving ability in older adults. Research related to the impact of chronic diseases, medications, visual problems, and various neurologic disorders should provide guidance to clinicians in the assessment of driving ability. Performance-based functional assessment, including the use of driving simulators and road tests, may provide information that is useful in the evaluation and rehabilitation of possibly impaired older drivers. Further research related to human, vehicular, and environmental factors and the development of intervention strategies for prevention of crashes and crash-related injuries will reduce the risk of injury and death in older adults.
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Review |
33 |
51 |
16
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Zhang SX, Underwood M, Landfield A, Huang FF, Gison S, Geddes JW. Cytoskeletal disruption following contusion injury to the rat spinal cord. J Neuropathol Exp Neurol 2000; 59:287-96. [PMID: 10759184 DOI: 10.1093/jnen/59.4.287] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Following experimental spinal cord injury (SCI), there is a delayed loss of neurofilament proteins but relatively little is known regarding the status of other cytoskeletal elements. The purpose of the present study was to compare the extent and time course of the MAP2 loss with that of neurofilament proteins, and to examine tau protein levels and distribution following SCI. Within 1 to 6 hours following SCI, there is rapid loss of MAP2, tau, and nonphosphorylated neurofilament proteins at the injury site. In contrast, the loss of phosphorylated neurofilament proteins was not significant until 1 week postinjury. In addition to the loss of MAP2 protein, there was extensive beading of MAP2-immunoreactive dendrites extending into the white matter. This was most pronounced 1 hour after injury and gradually resolved such that beading was no longer evident 2 weeks after SCI. The time course of beading resolution is similar to that of behavioral recovery following SCI, but the functional significance of the beading remains to be determined. Together, these results demonstrate that there are 2 phases of cytoskeletal disruption following SCI; a rapid loss of MAP2, tau, and nonphosphorylated neurofilament proteins, and a delayed loss of phosphorylated neurofilaments.
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Comparative Study |
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51 |
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Meneses SRF, Goode AP, Nelson AE, Lin J, Jordan JM, Allen KD, Bennell KL, Lohmander LS, Fernandes L, Hochberg MC, Underwood M, Conaghan PG, Liu S, McAlindon TE, Golightly YM, Hunter DJ. Clinical algorithms to aid osteoarthritis guideline dissemination. Osteoarthritis Cartilage 2016; 24:1487-99. [PMID: 27095418 DOI: 10.1016/j.joca.2016.04.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/14/2016] [Accepted: 04/04/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Numerous scientific organisations have developed evidence-based recommendations aiming to optimise the management of osteoarthritis (OA). Uptake, however, has been suboptimal. The purpose of this exercise was to harmonize the recent recommendations and develop a user-friendly treatment algorithm to facilitate translation of evidence into practice. METHODS We updated a previous systematic review on clinical practice guidelines (CPGs) for OA management. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation for quality and the standards for developing trustworthy CPGs as established by the National Academy of Medicine (NAM). Four case scenarios and algorithms were developed by consensus of a multidisciplinary panel. RESULTS Sixteen guidelines were included in the systematic review. Most recommendations were directed toward physicians and allied health professionals, and most had multi-disciplinary input. Analysis for trustworthiness suggests that many guidelines still present a lack of transparency. A treatment algorithm was developed for each case scenario advised by recommendations from guidelines and based on panel consensus. CONCLUSION Strategies to facilitate the implementation of guidelines in clinical practice are necessary. The algorithms proposed are examples of how to apply recommendations in the clinical context, helping the clinician to visualise the patient flow and timing of different treatment modalities.
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Review |
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45 |
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Andrews SR, Charnock SJ, Lakey JH, Davies GJ, Claeyssens M, Nerinckx W, Underwood M, Sinnott ML, Warren RA, Gilbert HJ. Substrate specificity in glycoside hydrolase family 10. Tyrosine 87 and leucine 314 play a pivotal role in discriminating between glucose and xylose binding in the proximal active site of Pseudomonas cellulosa xylanase 10A. J Biol Chem 2000; 275:23027-33. [PMID: 10767281 DOI: 10.1074/jbc.m000128200] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The Pseudomonas family 10 xylanase, Xyl10A, hydrolyzes beta1, 4-linked xylans but exhibits very low activity against aryl-beta-cellobiosides. The family 10 enzyme, Cex, from Cellulomonas fimi, hydrolyzes aryl-beta-cellobiosides more efficiently than does Xyl10A, and the movements of two residues in the -1 and -2 subsites are implicated in this relaxed substrate specificity (Notenboom, V., Birsan, C., Warren, R. A. J., Withers, S. G., and Rose, D. R. (1998) Biochemistry 37, 4751-4758). The three-dimensional structure of Xyl10A suggests that Tyr-87 reduces the affinity of the enzyme for glucose-derived substrates by steric hindrance with the C6-OH in the -2 subsite of the enzyme. Furthermore, Leu-314 impedes the movement of Trp-313 that is necessary to accommodate glucose-derived substrates in the -1 subsite. We have evaluated the catalytic activities of the mutants Y87A, Y87F, L314A, L314A/Y87F, and W313A of Xyl10A. Mutations to Tyr-87 increased and decreased the catalytic efficiency against 4-nitrophenyl-beta-cellobioside and 4-nitrophenyl-beta-xylobioside, respectively. The L314A mutation caused a 200-fold decrease in 4-nitrophenyl-beta-xylobioside activity but did not significantly reduce 4-nitrophenyl-beta-cellobioside hydrolysis. The mutation L314A/Y87A gave a 6500-fold improvement in the hydrolysis of glucose-derived substrates compared with xylose-derived equivalents. These data show that substantial improvements in the ability of Xyl10A to accommodate the C6-OH of glucose-derived substrates are achieved when steric hindrance is removed.
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Underwood M, Ashby D, Carnes D, Castelnuovo E, Cross P, Harding G, Hennessy E, Letley L, Martin J, Mt-Isa S, Parsons S, Spencer A, Vickers M, Whyte K. Topical or oral ibuprofen for chronic knee pain in older people. The TOIB study. Health Technol Assess 2008; 12:iii-iv, ix-155. [PMID: 18505668 DOI: 10.3310/hta12220] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To determine whether GPs should advise their older patients with chronic knee pain to use topical or oral non-steroidal anti-inflammatory drugs (NSAIDs). DESIGN An equivalence study was designed to compare the effect of advice to use preferentially oral or topical ibuprofen (an NSAID) on knee pain and disability, NSAID-related adverse effects and NHS/societal costs, using a randomised controlled trial (RCT) and a patient preference study (PPS). Reasons for patient preferences for topical or oral preparations, and attitudes to adverse effects, were explored in a qualitative study. SETTING Twenty-six general practices in the UK. PARTICIPANTS Participants comprised 585 people with knee pain, aged 50 years or over; 44% were male, mean age 64 years. The RCT had 282 participants: 144 in the oral group and 138 in the topical group. The PPS had 303 participants: 79 in the oral group and 224 in the topical group. INTERVENTIONS Advice to use preferentially oral or topical NSAIDs for knee pain. OUTCOME MEASURES The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were the Short Form with 36 Items (SF-36), perceived troublesomeness of knee pain, satisfaction with health status, major adverse effects (unplanned hospital admissions and deaths) and minor adverse events over 12 months. The health economic analysis measured the comparative cost per quality-adjusted life-year (QALY) from both an NHS and a societal perspective over 1 and 2 years. RESULTS Changes in the global WOMAC score at 12-months were equivalent in both studies: topical - oral, RCT difference=2 [95% confidence interval (CI) -2 to 6], PPS difference=1 (95% CI -4 to 6). There were no differences in the secondary outcomes, except for a suggestion, in the RCT, that those in the topical group were more likely to have more severe overall pain and disability as measured by the chronic pain grade, and more likely to report changing treatment because of inadequate pain relief. There were no differences in the rate of major adverse effects but some differences in the number of minor ones. In the RCT, 17% and 10% in the oral and the topical group, respectively, had a defined respiratory adverse effect (95% CI of difference -17% to -2.0%); after 12 months, the change in serum creatinine was 3.7 mmol/l (95% CI 0.9 to 6.5) less favourable in the oral than in the topical group, and 11% of those in the oral group reported changing treatment because of adverse effects compared with 1% in the topical group (p=0.02). None of these differences were seen in the PPS. Oral NSAIDs cost the NHS 191 pounds and 72 pounds more per participant over 1 year in the RCT and PPS respectively. In the RCT the cost per QALY in the oral group, from an NHS perspective, was in the range 9000-12,000 pounds. In the PPS it was 2564 pounds over 1 year, but over 2 years the oral route was more cost-effective. Patient preference for medication type was affected by previous experience of medication (including adverse reactions), other illness, pain elsewhere, anecdotes, convenience, severity of pain and perceived degree of degeneration. Lack of understanding about knee pain and the action of medication led to increased tolerance of symptoms. Potentially important symptoms may inadvertently have been disregarded, increasing participants' risk of suffering a major adverse effect. CONCLUSIONS Advice to use either oral or topical preparations has an equivalent effect on knee pain, but oral NSAIDs appear to produce more minor adverse effects than topical NSAIDs. Generally, these results support advising older people with knee pain to use topical rather than oral NSAIDS. However, for patients who prefer oral NSAID preparations rather than a topical NSAID, particularly those with more widespread or severe pain, the oral route is a reasonable treatment option, provided that patients are aware of the risks of potentially serious adverse effects from oral medication. Further research is needed into strategies to change prescribing behaviour and ensure that older patients are aware of the potential risks and benefits of using NSAIDs. Observational studies are needed to estimate rates of different predefined minor adverse effects associated with the use of oral NSAIDs in older people as are long-term studies of topical NSAIDs in those for whom oral NSAIDs are not appropriate.
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Randomized Controlled Trial |
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Birdi I, Caputo M, Underwood M, Bryan AJ, Angelini GD. The effects of cardiopulmonary bypass temperature on inflammatory response following cardiopulmonary bypass. Eur J Cardiothorac Surg 1999; 16:540-5. [PMID: 10609905 DOI: 10.1016/s1010-7940(99)00301-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The inflammatory response to cardiopulmonary bypass is believed to play an important role in end organ dysfunction after open heart surgery and may be more profound after normothermic systemic perfusion. The aim of the present study was to investigate the effects of cardiopulmonary bypass temperature on the production of markers of inflammatory activity after coronary artery surgery. METHODS Forty-five low risk patients undergoing elective coronary artery surgery were prospectively randomized into three groups: hypothermia (28 degrees C, n = 15), moderate hypothermia (32 degrees C, n = 15), and normothermia (37 degrees C, n = 15). All patients received cold antegrade crystalloid cardioplegia and topical myocardial cooling with saline at 4 degrees C. Serum samples were collected for the estimation of neutrophil elastase, interleukin 8, C3d, and IgG under ice preoperatively, 5 min after heparinisation, 30 min following start of CPB, at the end of CPB, 5 min after protamine administration, and 4, 12 and 24 h postoperatively. RESULTS Patients were similar with regard to preoperative and intraoperative characteristics (age, sex, severity of symptoms, number of grafts performed, aortic cross clamp time, cardiopulmonary bypass time). Neutrophil elastase concentration increased markedly as early as 30 min after the onset of cardiopulmonary bypass and peaked 5 min after protamine administration. Levels were not significantly different between the three groups. A similar finding was apparent for C3d release. Interleukin 8 concentrations also demonstrated a considerable increase related to cardiopulmonary bypass in all groups, but there was a significantly more rapid decline in interleukin 8 concentrations in the normothermic group in the postoperative period. Eluted IgG fraction showed a much earlier peak concentration than the other markers, occurring within 30 min of the start of cardiopulmonary bypass. Levels reached a plateau, before declining soon after the end of bypass and remained higher than preoperative values at 24 h. There was no difference between the three groups. The cumulative release of all markers was calculated from the concentration-time curves, and was not statistically different between groups. CONCLUSION Normothermic systemic perfusion was not shown to produce a more profound inflammatory response compared to hypothermic and moderately hypothermic cardiopulmonary bypass.
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Clinical Trial |
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Rahman A, Reed E, Underwood M, Shipley ME, Omar RZ. Factors affecting self-efficacy and pain intensity in patients with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic. Rheumatology (Oxford) 2008; 47:1803-8. [PMID: 18835878 DOI: 10.1093/rheumatology/ken377] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Chronic musculoskeletal pain is a very common and costly health problem. Patients presenting to rheumatology clinics with chronic pain can be difficult to manage. We studied 354 patients referred to a rheumatology chronic pain clinic over 5 yrs to identify factors affecting their self-efficacy and intensity of pain. METHODS We collected data for each patient, covering demographic and psychosocial factors, characteristics of their pain and previous treatment. We measured self-efficacy using a validated questionnaire, and pain intensity (PI) on an NRS. We performed multiple regression analysis to determine as to which factors were independently associated with these outcomes. RESULTS Despite extensive previous investigations and treatment, these patients had low self-efficacy [median = 26.5, interquartile range (IQR) 15-38, best possible = 60] and high PI scores (median = 7, worst possible = 10, IQR 5-9). Low self-efficacy was most clearly associated with depressive symptoms and not being employed. PI was most clearly associated with depressive symptoms, extensive pain and lower level of education. CONCLUSION Community-based studies suggest psychosocial factors are very important in determining outcomes in patients with chronic pain. This study suggests that the same is true in patients referred to rheumatologists due to chronic musculoskeletal pain and that these factors-particularly depressive symptoms and not being employed-are more important than site or duration of pain in those patients.
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Research Support, Non-U.S. Gov't |
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35 |
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Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A, Spencer A, Thorogood M, Atherton N, Bremner SA, Devine A, Diaz-Ordaz K, Ellard DR, Potter R, Spanjers K, Taylor SJC. Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA). Health Technol Assess 2014; 17:1-281. [PMID: 23632142 DOI: 10.3310/hta17180] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population. OBJECTIVE To evaluate the impact of a 'whole-home' intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents. DESIGN A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison). SETTING Seventy-eight care homes in Coventry and Warwickshire and north-east London. PARTICIPANTS Care home residents aged ≥ 65 years. INTERVENTIONS Control intervention: Depression awareness training programme for care home staff. Active intervention: A 'whole-home' exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group. MAIN OUTCOME MEASURES Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death. RESULTS We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI -0.33 to 0.60) and depressed cohort (0.22, 95% CI -0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI -£655 to £1404); the mean difference in quality-adjusted life-year was -0.0014 (95% CI -0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly. CONCLUSION The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents. TRIAL REGISTRATION Current Controlled Trials ISRCTN43769277. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.
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Research Support, Non-U.S. Gov't |
11 |
34 |
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Desch KC, Ozel AB, Halvorsen M, Jacobi PM, Golden K, Underwood M, Germain M, Tregouet DA, Reitsma PH, Kearon C, Mokry L, Richards JB, Williams F, Li JZ, Goldstein D, Ginsburg D. Whole-exome sequencing identifies rare variants in STAB2 associated with venous thromboembolic disease. Blood 2020; 136:533-541. [PMID: 32457982 PMCID: PMC7393257 DOI: 10.1182/blood.2019004161] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/12/2020] [Indexed: 12/13/2022] Open
Abstract
Deep vein thrombosis and pulmonary embolism, collectively defined as venous thromboembolism (VTE), are the third leading cause of cardiovascular death in the United States. Common genetic variants conferring increased varying degrees of VTE risk have been identified by genome-wide association studies (GWAS). Rare mutations in the anticoagulant genes PROC, PROS1 and SERPINC1 result in perinatal lethal thrombosis in homozygotes and markedly increased VTE risk in heterozygotes. However, currently described VTE variants account for an insufficient portion of risk to be routinely used for clinical decision making. To identify new rare VTE risk variants, we performed a whole-exome study of 393 individuals with unprovoked VTE and 6114 controls. This study identified 4 genes harboring an excess number of rare damaging variants in patients with VTE: PROS1, STAB2, PROC, and SERPINC1. At STAB2, 7.8% of VTE cases and 2.4% of controls had a qualifying rare variant. In cell culture, VTE-associated variants of STAB2 had a reduced surface expression compared with reference STAB2. Common variants in STAB2 have been previously associated with plasma von Willebrand factor and coagulation factor VIII levels in GWAS, suggesting that haploinsufficiency of stabilin-2 may increase VTE risk through elevated levels of these procoagulants. In an independent cohort, we found higher von Willebrand factor levels and equivalent propeptide levels in individuals with rare STAB2 variants compared with controls. Taken together, this study demonstrates the utility of gene-based collapsing analyses to identify loci harboring an excess of rare variants with functional connections to a complex thrombotic disease.
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Research Support, N.I.H., Extramural |
5 |
33 |
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Taylor S, Bestall J, Cotter S, Falshaw M, Hood S, Parsons S, Wood L, Underwood M. Clinical service organisation for heart failure. Cochrane Database Syst Rev 2005:CD002752. [PMID: 15846638 PMCID: PMC4167847 DOI: 10.1002/14651858.cd002752.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed. OBJECTIVES To assess the effectiveness of disease management interventions for patients with CHF. SEARCH STRATEGY We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field. SELECTION CRITERIA Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care. DATA COLLECTION AND ANALYSIS At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary. MAIN RESULTS Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions. AUTHORS' CONCLUSIONS The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.
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Meta-Analysis |
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25
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Brealey S, Burton K, Coulton S, Farrin A, Garratt A, Harvey E, Letley L, Martin J, Klaber MJ, Russell I, Torgerson D, Underwood M, Vickers M, Whyte K, Williams M. UK Back pain Exercise And Manipulation (UK BEAM) trial--national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578]. BMC Health Serv Res 2003; 3:16. [PMID: 12892566 PMCID: PMC194218 DOI: 10.1186/1472-6963-3-16] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2003] [Accepted: 08/01/2003] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Low back pain has major health and social implications. Although there have been many randomised controlled trials of manipulation and exercise for the management of low back pain, the role of these two treatments in its routine management remains unclear. A previous trial comparing private chiropractic treatment with National Health Service (NHS) outpatient treatment, which found a benefit from chiropractic treatment, has been criticised because it did not take treatment location into account. There are data to suggest that general exercise programmes may have beneficial effects on low back pain. The UK Medical Research Council (MRC) has funded this major trial of physical treatments for back pain, based in primary care. It aims to establish if, when added to best care in general practice, a defined package of spinal manipulation and a defined programme of exercise classes (Back to Fitness) improve participant-assessed outcomes. Additionally the trial compares outcomes between participants receiving the spinal manipulation in NHS premises and in private premises. DESIGN Randomised controlled trial using a 3 x 2 factorial design. METHODS We sought to randomise 1350 participants with simple low back pain of at least one month's duration. These came from 14 locations across the UK, each with a cluster of 10-15 general practices that were members of the MRC General Practice Research Framework (GPRF). All practices were trained in the active management of low back pain. Participants were randomised to this form of general practice care only, or this general practice care plus manipulation, or this general practice care plus exercise, or this general practice care plus manipulation followed by exercise. Those randomised to manipulation were further randomised to receive treatment in either NHS or private premises. Follow up was by postal questionnaire one, three and 12 months after randomisation. The primary analysis will consider the main treatment effects before interactions between the two treatment packages. Economic analysis will estimate the cost per unit of health utility gained by adding either or both of the treatment packages to general practice care.
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Clinical Trial |
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