Elaine Beller

Alterations of Left Ventricular Myocardial Characteristics Associated With Obesity

Background—Obesity is associated with heart failure, but an effect of weight, independent of comorbidities, on cardiac structure and function is not well established. We sought whether body mass index (BMI) and insulin levels were associated with subclinical myocardial disturbances. Methods and Results—Transthoracic echocardiography, myocardial Doppler-derived systolic (sm) and early diastolic velocity (em), strain and strain rate imaging and tissue characterization with cyclic variation (CVIB), and calibrated integrated backscatter (cIB) were obtained in 109 overweight or obese subjects and 33 referents (BMI <25 kg/m2). BMI correlated with left ventricular (LV) mass and wall thickness (P<0.001). Severely obese subjects (BMI >35) had reduced LV systolic and diastolic function and increased myocardial reflectivity compared with referents, evidenced by lower average long-axis strain, sm, cIB, lower CVIB, and reduced em, whereas LV ejection fraction remained normal. Differences in regional or global strain, sm, and em were identified between the severely obese (BMI >35) and the referent patients (P<0.001). Similar but lesser degrees of reduced function by sm, em, and basal septal strain and increased reflectivity by cIB were present in overweight (BMI, 25 to 29.9) and mildly obese (BMI, 30 to 35) groups (P<0.05). Although tissue Doppler measures were not associated with duration of obesity, they did correlate with fasting insulin levels and reduced exercise capacity. BMI was independently related to average LV strain (&bgr;=0.40, P=0.02), sm (&bgr;=−0.36, P=0.002), and em (&bgr;=−0.41, P<0.001). Conclusions—Overweight subjects without overt heart disease have subclinical changes of LV structure and function even after adjustment for mean arterial pressure, age, gender, and LV mass.

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

Prevalence of attention-deficit/ Hyperactivity disorder: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE: Overdiagnosis and underdiagnosis of attention-deficit/hyperactivity disorder (ADHD) are widely debated, fueled by variations in prevalence estimates across countries, time, and broadening diagnostic criteria. We conducted a meta-analysis to: establish a benchmark pooled prevalence for ADHD; examine whether estimates have increased with publication of different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and explore the effect of study features on prevalence. METHODS: Medline, PsycINFO, CINAHL, Embase, and Web of Science were searched for studies with point prevalence estimates of ADHD. We included studies of children that used the diagnostic criteria from DSM-III, DSM-III-R and DSM-IV in any language. Data were extracted on sampling procedure, sample characteristics, assessors, measures, and whether full or partial criteria were met. RESULTS: The 175 eligible studies included 179 ADHD prevalence estimates with an overall pooled estimate of 7.2% (95% confidence interval: 6.7 to 7.8), and no statistically significant difference between DSM editions. In multivariable analyses, prevalence estimates for ADHD were lower when using the revised third edition of the DSM compared with the fourth edition (P = .03) and when studies were conducted in Europe compared with North America (P = .04). Few studies used population sampling with random selection. Most were from single towns or regions, thus limiting generalizability. CONCLUSIONS: Our review provides a benchmark prevalence estimate for ADHD. If population estimates of ADHD diagnoses exceed our estimate, then overdiagnosis may have occurred for some children. If fewer, then underdiagnosis may have occurred.

Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

Objective To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy. Design Prospective, single blind, randomised clinical trial. Setting Single centre trial within a community setting in Brisbane, Australia. Participants 179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months. Interventions Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy. Main outcome measures Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks. Results Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks (relative risk reduction 0.66, 99% confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks. Conclusion While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses. Trial registration Australian Clinical Trials Registry ACTRN012605000463673 and ClinicalTrials.gov NCT00118521.

Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? - A preliminary RCT

Abstract Patients with chronic whiplash associated disorders present with varied sensory, motor and psychological features. In this first instance it was questioned whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome. A randomised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question. Participants were randomly allocated to receive either a multimodal physiotherapy program (MPT) or a self‐management program (SMP) (advice and exercise). In the randomisation process, participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia. The intervention period was 10 weeks and outcomes were assessed immediately following treatment. Even with the presence of sensory hypersensitivity in 72.5% of subjects, both groups reported some relief of neck pain and disability (Neck Disability Index) and it was superior in the group receiving multimodal physiotherapy (p = 0.04). Post‐hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia. Further research is required to test the validity of this sub‐group observation and to test the effect of the intervention in the long term.

Increasing value and reducing waste in biomedical research regulation and management

After identification of an important research question and selection of an appropriate study design, waste can arise from the regulation, governance, and management of biomedical research. Obtaining regulatory and governance approval has become increasingly burdensome and disproportionate to the conceivable risks to research participants. Regulation and governance involve interventions that are assumed to be justified in the interests of patients and the public, but they can actually compromise these interests. Inefficient management of the procedural conduct of research is wasteful, especially if it results in poor recruitment and retention of participants in well designed studies addressing important questions. These sources of waste can be minimised if the following four recommendations are addressed. First, regulators should use their influence to reduce other causes of waste and inefficiency in research. Second, regulators and policy makers should work with researchers, patients, and health professionals to streamline and harmonise the laws, regulations, guidelines, and processes that govern whether and how research can be done, and ensure that they are proportionate to the plausible risks associated with the research. Third, researchers and research managers should increase the efficiency of recruitment, retention, data monitoring, and data sharing in research through use of research designs known to reduce inefficiencies, and further research should be done to learn how efficiency can be increased. Finally, everyone, particularly those responsible for health-care systems, should promote integration of research into everyday clinical practice. Regulators and researchers should monitor adherence to each of these recommendations and publish metrics.

PRISMA for Abstracts: Reporting Systematic Reviews in Journal and Conference Abstracts

Elaine Beller and colleagues from the PRISMA for Abstracts group provide a reporting guidelines for reporting abstracts of systematic reviews in journals and at conferences.

Which health-related quality of life score? A comparison of alternative utility measures in patients with Type 2 diabetes in the ADVANCE trial

BackgroundDiabetes has a high burden of illness both in life years lost and in disability through related co-morbidities. Accurate assessment of the non-mortality burden requires appropriate health-related quality of life and summary utility measures of which there are several contenders. The study aimed to measure the impact of diabetes on various health-related quality of life domains, and compare several summary utility measures.MethodsIn the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) study, 978 Australian patients with Type 2 diabetes completed two health-related quality of life questionnaires at baseline: the EQ-5D and the SF-36v2, from which nine summary utility measures were calculated, and compared. The algorithms were grouped into four classes: (i) based on the EQ-5D; (ii) using fewer items than those in the SF-12 (iii) using the items in the SF-12; and (iv) using all items of the SF-36.ResultsOverall health-related quality of life of the subjects was good (mean utility ranged from 0.68 (±0.08) to 0.85(±0.14) over the nine utility measures) and comparable to patients without diabetes. Summary indices were well correlated with each other (r = 0.76 to 0.99), and showed lower health-related quality of life in patients with major diabetes-related events such as stroke or myocardial infarction. Despite the smaller number of items used in the scoring of the EQ-5D, it generally performed at least as well as SF-36 based methods. However, all utility measures had some limitation such as limited range or ceiling effects.ConclusionThe summary utility measures showed good agreement, and showed good discrimination between major and minor health state changes. However, EQ-5D based measures performed as well and are generally simpler to use.

Are systematic reviews up-to-date at the time of publication?

BackgroundSystematic reviews provide a synthesis of evidence for practitioners, for clinical practice guideline developers, and for those designing and justifying primary research. Having an up-to-date and comprehensive review is therefore important. Our main objective was to determine the recency of systematic reviews at the time of their publication, as measured by the time from last search date to publication. We also wanted to study the time from search date to acceptance, and from acceptance to publication, and measure the proportion of systematic reviews with recorded information on search dates and information sources in the abstract and full text of the review.MethodsA descriptive analysis of published systematic reviews indexed in Medline in 2009, 2010 and 2011 by three reviewers, independently extracting data.ResultsOf the 300 systematic reviews included, 271 (90%) provided the date of search in the full-text article, but only 141 (47%) stated this in the abstract. The median (standard error; minimum to maximum) survival time from last search to acceptance was 5.1 (0.58; 0 to 43.8) months (95% confidence interval = 3.9 to 6.2) and from last search to first publication time was 8.0 (0.35; 0 to 46.7) months (95% confidence interval = 7.3 to 8.7), respectively. Of the 300 reviews, 295 (98%) stated which databases had been searched, but only 181 (60%) stated the databases in the abstract. Most researchers searched three (35%) or four (21%) databases. The top-three most used databases were MEDLINE (79%), Cochrane library (76%), and EMBASE (64%).ConclusionsBeing able to identify comprehensive, up-to-date reviews is important to clinicians, guideline groups, and those designing clinical trials. This study demonstrates that some reviews have a considerable delay between search and publication, but only 47% of systematic review abstracts stated the last search date and 60% stated the databases that had been searched. Improvements in the quality of abstracts of systematic reviews and ways to shorten the review and revision processes to make review publication more rapid are needed.

Two perspectives of proxy reporting of health-related quality of life using the Euroqol-5D, an investigation of agreement.

Background:Proxy-reporting has been proposed as an alternative to self-report of health-related quality of life (HRQoL) for patients with poor cognition. There are 2 possible perspectives from which to complete a proxy-report, answer as the patient would (proxy-patient) or from the proxys own perspective (proxy-proxy). Most research has not differentiated between perspectives. Agreement between patient and proxy-reports from either perspective has not been investigated using the Euroqol-5D (EQ-5D) among elderly hospital patients undergoing rehabilitation. Objectives:Identify agreement levels between proxy-patient and patient self-report as well as proxy-proxy and patient self-report of the EQ-5D and investigate interaction effects of timing (admission vs. discharge) and basic cognition (intact vs. not intact). Research Design:Repeated measures, inter-rater agreement investigation of clinician proxy-report, and patient self-report incorporating; proxy-patient reports (perspective A) and proxy-proxy reports (perspective B). Subjects:Geriatric rehabilitation patients (n = 272) and their proxies (treating physiotherapists n = 29). Measures:EQ-5D for HRQoL and Mini Mental State Examination for cognition. Results:One hundred fifty (89%) proxy-patient and 130 (98%) proxy-proxy datasets were complete, 51 perspective A and 52 perspective B patients did not have basic cognition intact. Proxy-patient assessments had strong agreement with self-report at discharge across all cognition levels (kappa = 0.76–0.95), but at admission had stronger agreement among patients with better cognition (kappa = 0.70–0.86) than patients with lower cognition (kappa = 0.47–0.76). At admission and discharge proxy-proxy assessments generally had moderate agreement with self-report among patients with poor cognition on most domains with proxies giving lower scores than patients (kappa = 0.23–0.81), this is in contrast to proxy-proxy assessments and patients with better cognition (kappa = 0.55–0.95). Conclusions:Clinician (physiotherapist) proxy-reports among this population generally had good agreement with patient self-report though this was affected by proxy perspective, patient cognition, and timing.