Catherine Beverley

Ultrasonic locating devices for central venous cannulation: meta-analysis

Abstract Objectives To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation. Data sources 15 electronic bibliographic databases, covering biomedical, science, social science, health economics, and grey literature. Design Systematic review and meta-analysis of randomised controlled trials. Populations Patients scheduled for central venous access. Intervention reviewed Guidance using real time two dimensional ultrasonography or Doppler needles and probes compared with the anatomical landmark method of cannulation. Data extraction Risk of failed catheter placement (primary outcome), risk of complications from placement, risk of failure on first attempt at placement, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation. Data synthesis 18 trials (1646 participants) were identified. Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants confirmed a higher success rate with two dimensional ultrasonography for internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided cannulation of the internal jugular vein in adults was more successful than the landmark method (0.39, 0.17 to 0.92), but the landmark method was more successful for subclavian vein procedures (1.48, 1.03 to 2.14). No significant difference was found between these techniques for cannulation of the internal jugular vein in infants. An indirect comparison of relative risks suggested that two dimensional ultrasonography would be more successful than Doppler guidance for subclavian vein procedures in adults (0.09, 0.02 to 0.38). Conclusions Evidence supports the use of two dimensional ultrasonography for central venous cannulation.

The acceptability to patients of computerized cognitive behaviour therapy for depression: a systematic review.

BACKGROUND Cognitive behaviour therapy (CBT) is widely used to treat depression. However, CBT is not always available to patients because of a shortage of therapists and long waiting times. Computerized CBT (CCBT) is one of several alternatives currently available to treat patients with depression. Evidence of its clinical effectiveness has led to programs being used increasingly within the UK and elsewhere. However, little information is available regarding the acceptability of CCBT to patients. METHOD A systematic review of sources of information on acceptability to patients of CCBT for depression. RESULTS Sources of information on acceptability included: recruitment rates, patient drop-outs and patient-completed questionnaires. We identified 16 studies of CCBT for the treatment of depression that provided at least some information on these sources. Limited information was provided on patient take-up rates and recruitment methods. Drop-out rates were comparable to other forms of treatment. Take-up rates, when reported, were much lower. Six of the 16 studies included specific questions on patient acceptability or satisfaction although information was only provided for those who had completed treatment. Several studies have reported positive expectancies and high satisfaction in routine care CCBT services for those completing treatment. CONCLUSIONS Trials of CCBT should include more detailed information on patient recruitment methods, drop-out rates and reasons for dropping out. It is important that well-designed surveys and qualitative studies are included alongside trials to determine levels and determinants of patient acceptability.

Ultrasound for central venous cannulation: economic evaluation of cost effectiveness.

We compared the economics of using two‐dimensional ultrasound locating devices and more traditional landmark methods for central venous cannulation in the National Health Service (NHS). The evaluation consisted of a systematic review of randomised controlled trials and an economic evaluation using decision analytic cost‐effectiveness modelling. Incremental costs per complication avoided associated with landmark and ultrasound central venous cannulation were modelled for patients scheduled for central venous cannulation. The marginal economic cost of using ultrasound for central venous cannulation was less than £10 per procedure, assuming that a machine is used for 15 procedures each week. The base case scenario implied that £2000 worth of resource savings result for every 1000 procedures undertaken and 90 avoided complications. Sensitivity analysis indicated that the results of modelling appear robust to the central assumptions used. Ultrasound guidance used in central venous cannulation procedures saves NHS resources even with conservative modelling assumptions.

COMPUTERIZED COGNITIVE BEHAVIOUR THERAPY: A SYSTEMATIC REVIEW

Depression, anxiety disorders and phobias are common mental health problems associated with considerable occupational and interpersonal impairment. Although there is substantial evidence to support the use of cognitive behaviour therapy (CBT) in the treatment of these disorders, access is limited. Computerized cognitive behaviour therapy (CCBT) is one of a variety of aids to self-management that offer patients the potential benefits of CBT with less therapist involvement than therapist led CBT (TCBT). In this systematic review of the efficacy of CCBT, 16 studies were identified. Of these 11 were RCTS and the remaining 5 were pilot or cohort studies. The quality of studies ranged from poor to moderate (although the criteria used precluded the highest rating). In the studies comparing CCBT with TCBT, five studies showed CCBT have equivalent outcomes to TCBT. One study of depressed inpatients found TCBT to be significantly more effective than CCBT. Four studies found CCBT to be more effective than treatment as usual (TAU). Two studies found CCBT to be no more effective than TAU. Two studies compared CCBT with bibliotherapy. Of these, one study found CCBT to be as effective as bibliotherapy and one found bibliotherapy to be significantly more effective than CCBT on some outcome measures. Although the results of this review are not conclusive, CCBT is potentially useful in the treatment of anxiety disorders, depression and phobias. From the results of this review, we make three recommendations to improve the quality of research in this field, and suggest four areas requiring further research.

Computerised Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: A Systematic Review

Background: Computer-guided therapy is an innovative treatment strategy that could have an important role in the future of psychological treatment. This paper summarises the available published evidence that assesses the effectiveness of a computerised cognitive behaviour therapy (CCBT) for obsessive-compulsive disorder (OCD). Methods: Fifteen electronic bibliographic databases including Medline, Embase, the Cochrane Library, Cinahl, PsycINFO, Biological Abstracts, HMIC and NHS CRD databases were comprehensively searched in March 2004: [‘obsessive compulsive disorder’ (text and indexed terms)] AND [‘cognitive therapy’ (text and indexed terms)] AND [‘computer’ (text and indexed terms)]. Reference lists of included studies, guidelines, generic research, trials registers and specialist mental health sites were hand-searched. Results: The search produced 149 citations from which we identified two RCTs and two single-arm studies with relevant data. All four studies used one software programme – BTSteps.In the large RCT, YBOCS effect sizes for BTSteps, therapist-led cognitive behaviour therapy (TCBT) and relaxation (RLX) were 0.84, 1.22, and 0.35, respectively. The smaller RCT found significantly better outcomes with brief scheduled support compared to brief on-demand phone support. Conclusions: BTSteps was as good as TCBT for reducing time spent in rituals and obsessions and for improving the Work and Social Adjustment Scale (WSA), and was superior to RLX treatment. The available evidence also showed that improvement of OCD persisted beyond the end of CCBT. TCBT was more effective than CCBT for all patients overall though not in those who went on to start self-exposure. Such a system has the potential to widen the access to CBT in general and considerably shorten clinician-guided care.

A review of the clinical effectiveness of routine antenatal anti-D prophylaxis for rhesus-negative women who are pregnant.

In its mildest form, haemolytic disease of the newborn is detectable only in laboratory tests. However, severe disease causes physical disabilities and often mental retardation; in its most severe form, it causes intrauterine death. Haemolytic disease of the newborn therefore has potentially very serious consequences for human health and happiness. Haemolytic disease of the newborn is caused by the transplacental passage of anti-D antibodies from a RhDnegative mother to a RhD-positive fetus. Any feto-maternal haemorrhage in a RhD-negative mother pregnant with a RhD-positive fetus, whether at or before delivery of that infant, may stimulate the production of anti-D antibodies (a process known as sensitisation). The first RhD-positive infant is not harmed if the mother is sensitised at delivery, but may be affected if the mother is sensitised during pregnancy: one study found that, of 20 infants born to primigravidae who had antibodies before or at delivery, two were moderately affected (requiring exchange transfusion) and 16 were mildly affected. Because the severity of the disease is related to the level of antibodies in the maternal blood and the length of time for which the infant is exposed to them, subsequent RhD-positive infants born to a sensitised mother are likely to be progressively more severely affected. Some women do not have detectable anti-D after the index pregnancy, but nonetheless give a secondary immune response during a later pregnancy; they are described as having been ‘sensibilised’, rather than sensitised, by the index pregnancy. Prophylactic anti-D can suppress primary RhD immunisation. Routine postpartum anti-D immunoprophylaxis was introduced in the United Kingdom in 1969. Prophylaxis was extended in 1976 to include abortions and spontaneous miscarriages, and in 1981 to include a number of other potentially sensitising events. – 4 The guidelines were updated in 1991. Despite this, some women in the United Kingdom continued to become sensitised prior to delivery of the first pregnancy. In some cases, this could be attributed to failure to adhere to existing guidelines through lack of administration of (a) any, (b) enough or (c) timely anti-D in response to potential sensitising events in pregnancy. Audits found that guidelines were followed fully in only 59% to 79% of potentially sensitising events, and in one study only 11 out of 44 RhD-negative women undergoing amniocentesis (25%) received anti-D. A questionnaire survey found that, in the early 1990s, 77% of Accident and Emergency departments in England and Wales did not have a policy for treating with anti-D women who bled in early pregnancy. However, other women, estimated at between 55% and 80% of sensitised women, appeared to be sensitised in the absence of any identifiable risk event such as should have prompted the administration of anti-D (so-called silent sensitisation). As prophylactic anti-D has no effect in women who have already developed anti-D, however weak, it appeared that the most stringent adherence to existing guidelines could not prevent some instances of sensitisation. Attention therefore turned to routine antenatal anti-D prophylaxis as a possible means of reducing sensitisation rates. Owing to the lack of clarity concerning the available evidence for routine antenatal anti-D prophylaxis, and consequent ambiguity of guidance supporting its introduction, in 2001 the UK National Institute for Clinical Excellence (NICE) commissioned a systematic review of the available evidence for the clinical and cost effectiveness of a community programme of routine antenatal anti-D prophylaxis in pregnant RhD-negative women. This article is an abridged version of the systematic review; a more detailed review of the clinical effectiveness and cost effectiveness of such a programme is contained within the monograph.

Economics of tandem mass spectrometry screening of neonatal inherited disorders

OBJECTIVES The aim of this study was to evaluate the cost-effectiveness of neonatal screening for phenylketonuria (PKU) and medium-chain acyl-coA dehydrogenase (MCAD) deficiency using tandem mass spectrometry (tandem MS). METHODS A systematic review of clinical efficacy evidence and cost-effectiveness modeling of screening in newborn infants within a UK National Health Service perspective was performed. Marginal costs, life-years gained, and cost-effectiveness acceptability curves are presented. RESULTS Substituting the use of tandem MS for existing technologies for the screening of PKU increases costs with no increase in health outcomes. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS, with an operational range of 50,000 to 60,000 specimens per system per year, would result in a mean incremental cost of -pound 17,298 (-pound 129,174, pound 66,434) for each cohort of 100,000 neonates screened. This cost saving is associated with a mean incremental gain of 57.3 (28.0, 91.4) life-years. CONCLUSIONS Cost-effectiveness analysis using economic modeling indicates that substituting the use of tandem MS for existing technologies for the screening of PKU alone is not economically justified. However, the addition of screening for MCAD deficiency as part of a neonatal screening program for PKU using tandem MS would be economically attractive.

The economics of routine antenatal anti-D prophylaxis for pregnant women who are rhesus negative.

Objective  To investigate the economics of routine antenatal anti‐D prophylaxis in the prevention of haemolytic disease of the newborn, in support of the NICE appraisals process.

Health and social care information for visually‐impaired people

Purpose – The purpose of this study is to examine the health and social care information needs of people with a visual impairment; to identify the health and social care information sources used by visually‐impaired people seeking information; to identify differences in the information needs of people with different visual impairments; to examine ways in which developments in information provision may help to meet the needs of visually impaired people.Design/methodology/approach – In total, 28 semi‐structured interviews (face‐to‐face or telephone) were conducted with 31 visually impaired people living in or near Sheffield, UK. The participants included two groups: people with an age‐related visual impairment, and people with a visual impairment since birth or early childhood. Framework analysis was used to analyse the findings.Findings – Four major themes were identified: health and social care information needs, sources of health and social care information, possible improvements, and “intervening variab...