P Lina Santaguida

Reproducibility of impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) classification: a systematic review

Abstract Background: The classifications of impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) represent glucose levels above normal, but below the decision threshold for diabetes. We sought to determine what the reproducibility of these classifications was when repeat tests were performed by conducting a systematic review of the literature. Methods: All primary studies published in English of any study design were included. Studies were excluded if they did not follow the World Health Organization or American Diabetes Association diagnostic criteria, used whole blood as the specimen type, a glucose meter for analysis, or performed repeat testing greater than 8 weeks apart. Results: Five papers had reproducibility data for IGT or IFG, two of which where from the same population but sampled differently. The κ coefficients, indicating agreement between repeat tests that exceeded chance, indicated poor to fair agreement for IGT (0.04, 0.22, 0.38, 0.42) and moderate agreement for IFG (0.44 and 0.56). Similarly, the observed reproducibility was slightly lower for IGT (33%, 44%, 47%, 48%) compared to IFG (51%, 64%). In two studies for which data were available for both IGT and IFG, the average reproducibility was lower (49%) for the prediabetes group compared to the diabetes group (73%) or the normal group (93%). Conclusions: Poor reproducibility of IGT and IFG classification suggests caution should be exercised when interpreting a single test result. Clin Chem Lab Med 2007;45:1180–5.

An Overview of Systematic Reviews on Prognostic Factors in Neck Pain: Results from the International Collaboration on Neck Pain (ICON) Project

Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview). An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review

Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.

Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey

BackgroundClinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens.AimTo describe the utilization of interventions in patients with neck pain by clinicians.MethodsA cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain.ResultsThe survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41-66%) working in private practice (69-95%). Exercise and manual therapies were consistently (98-99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and ‘other’ interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics).ConclusionsThis survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.

Amantadine to enhance readiness for rehabilitation following severe traumatic brain injury

Primary objective: To evaluate the association between amantadine and recovery of consciousness from prolonged traumatic coma. Research design: A retrospective cohort study. Methods: Subjects included 123 adults with severe traumatic brain injury (TBI) admitted over a 10-year period who remained in coma despite becoming medically stable. Experimental interventions: Cases received 100–200 mg of amantadine twice daily. Main outcomes and results: 46.4% (13/28) of cases emerged from coma compared to 37.9% (36/95) of controls (p = 0.42). Somatosensory evoked potential (SSEP) was the only significant predictor of emergence from coma (p = 0.02), while SSEP, age and Glasgow Coma Score (GCS) significantly predicted time to emerge from coma (p < 0.05). Conclusions: Although the study and its design do not support the view that amantadine has an effect on recovery of consciousness; it remains safe, inexpensive and has few side effects. The lack of treatment alternatives and anecdotal support for its use may warrant further study. Prospective controlled trials would yield more definitive results.

Predictors of Surgical Outcomes Following Anterior Transposition of Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review

PURPOSE Although cubital tunnel syndrome is the second most common nerve entrapment neuropathy, few studies explore potential predictor(s) of surgical outcomes. The purpose of this systematic review was to determine which factors affect the postoperative outcome for patients who undertake anterior transposition of the ulnar nerve. METHODS We included all studies reporting predictor(s) of clinical, electrophysiological study, or functional outcome after any anterior transposition of the ulnar nerve. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL from 1980 to April 2011 and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality, and data extraction independently of each other. RESULTS We assessed 26 studies including 2 randomized controlled trials, 10 cohort studies, and 14 case series. Overall, the methodological quality of the studies ranged from low to moderate. Six aspects of prognosis were sufficiently studied for a narrative evidence synthesis on age, duration of symptom, severity of operative status, preoperative electrodiagnostic testing results, type of surgery, and work compensation status. Evidence was conflicting across studies in terms of both the direction and intensity of the impact of these 6 potential predictors on surgical outcomes. CONCLUSIONS Because of conflicting results, we were unable to conclude which predictor(s) affect surgical outcomes after anterior transposition of the ulnar nerve. Surgeons who are aware of only a limited number of prognostic studies and their limited scope of evidence may not appreciate the extent of the inconsistency about whether factors commonly viewed as prognostic actually have a noteworthy impact on outcomes achieved. Such factors may be identified in the future with higher-quality studies, because limitations in the current research undoubtedly contribute to the controversies observed.

An ICON Overview on Physical Modalities for Neck Pain and Associated Disorders

Introduction: Neck pain is common, can be disabling and is costly to society. Physical modalities are often included in neck rehabilitation programs. Interventions may include thermal, electrotherapy, ultrasound, mechanical traction, laser and acupuncture. Definitive knowledge regarding optimal modalities and dosage for neck pain management is limited. Purpose: To systematically review existing literature to establish the evidence-base for recommendations on physical modalities for acute to chronic neck pain. Methods: A comprehensive computerized and manual search strategy from January 2000 to July 2012, systematic review methodological quality assessment using AMSTAR, qualitative assessment using a GRADE approach and recommendation presentation was included. Systematic or meta-analyses of studies evaluating physical modalities were eligible. Independent assessment by at least two review team members was conducted. Data extraction was performed by one reviewer and checked by a second. Disagreements were resolved by consensus. Results: Of 103 reviews eligible, 20 were included and 83 were excluded. Short term pain relief - Moderate evidence of benefit: acupuncture, intermittent traction and laser were shown to be better than placebo for chronic neck pain. Moderate evidence of no benefit: pulsed ultrasound, infrared light or continuous traction was no better than placebo for acute whiplash associated disorder, chronic myofascial neck pain or subacute to chronic neck pain. There was no added benefit when hot packs were combined with mobilization, manipulation or electrical muscle stimulation for chronic neck pain, function or patient satisfaction at six month follow-up. Conclusions: The current state of the evidence favours acupuncture, laser and intermittent traction for chronic neck pain. Some electrotherapies show little benefit for chronic neck pain. Consistent dosage, improved design and long term follow-up continue to be the recommendations for future research.

Methodology used to develop the AANS/CNS management of brain metastases evidence-based clinical practice parameter guidelines

Brain metastases, which occur in approximately 20–40% of individuals with systemic cancer, represent a significant cause of morbidity and mortality and overwhelm all other types of brain tumors in terms of incidence and public health impact [1]. Considerable research has focused on improving survival and quality of life for this patient population. Given the expanding knowledge base and the rapid emergence of new therapies, the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), and the AANS/CNS Joint Tumor Section jointly funded an initiative to produce methodologically rigorous evidence-linked clinical practice parameter guidelines on this topic. The overall objective of this series of guideline papers is to provide the latest up-to-date evidence-based recommendations for the management of patients with brain metastases centering on eight questions related to commonly encountered clinical scenarios (Tables 1, 2, 3). Accomplishment of this goal required undertaking a systematic review of the literature. The McMaster University Evidence-based Practice Center (EPC), which is an academic research unit partially funded by an EPC grant from the Agency for Healthcare Research and Quality (AHRQ), with specialized expertise in evidence-based medicine and the development of systematic reviews, was contracted to performed the systematic review in consultation with the guideline panel assembled for the initiative. The McMaster EPC also served as facilitators during the guideline development, consensus and writing processes. The Joint Tumor Section of the AANS/CNS recruited representatives from surgical neuro-oncology (including microsurgical, stereotactic radiosurgery and experimental therapies), radiation oncology (fractionated radiotherapy, stereotactic radiosurgery and brachytherapy) and medical neuro-oncology (chemotherapy and experimental therapies) to form a multi-disciplinary panel of 17 clinical experts who developed the evidence-based practice guidelines from the systematic review results (Table 4). These seventeen experts across several disciplines were all nominated and selected by the Executive Committee of the AANS/CNS Tumor Section based on their clinical expertise and recognized contributions to the field of neurooncology in general and brain metastases in particular. The Tumor Section Executive Committee then selected a chairperson for this endeavor to organize and lead the effort, serving also to encourage and manage debate on the various topics involved.

Use of Outcome Measures in Managing Neck Pain: An International Multidisciplinary Survey

Purpose: To determine the outcome measures practice patterns in the neck pain management of various health disciplines. Methods: A survey of 381 clinicians treating patients with neck pain was conducted. Results: Respondents were more commonly male (54%) and either chiropractors (44%) or physiotherapists (32%). The survey was international (24 countries with Canada having the largest response (44%)). The most common assessment was a single-item pain assessment (numeric or visual analog) used by 75% of respondents. Respondents sometimes or routinely used the Neck Disability Index (49%), the Patient Specific Functional Scale (28%), and the Disabilities of the Arm, Shoulder and Hand (32%). Work status was recorded in terms of time lost by more than 50% of respondents, but standardized measures of work limitations or functional capacity testing were rarely used. The majority of respondents never used fear of movement, psychological distress, quality of life, participation measures, or global ratings of change (< 10% routinely use). Use of impairment measurers was prevalent, but the type selected was variable. Quantitative sensory testing was used sometimes or routinely by 53% of respondents, whereas 26% never used it. Ratings of segmental joint mobility were commonly used to assess motion (44% routinely use), whereas 66% of respondents never used inclinometry. Neck muscle strength, postural alignment and upper extremity coordination were assessed sometimes or routinely by a majority of respondents (>56%). With the exception of numeric pain ratings and verbal reporting of work status, all outcomes measures were less frequently used by physicians. Years of practice did not affect practice patterns, but reimbursement did affect selection of some outcome measures. Conclusions: Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggessts overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement in practice. International consensus and better clinical measurement evidence are needed to support this.

Performance of BNP and NT-proBNP for diagnosis of heart failure in primary care patients: a systematic review

National and international guidelines have been published recommending the use of natriuretic peptides as an aid to the diagnosis of heart failure (HF) in acute settings; however, few specific recommendations exist for governing the use of these peptides in primary care populations. To summarize the available data relevant to the diagnosis of HF in primary care patient population, we systematically reviewed the literature to identify original articles that investigated the diagnostic accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) in primary care settings. The search yielded 25,864 articles in total: 12 investigating BNP and 20 investigating NT-proBNP were relevant to our objective and included in the review. QUADAS-2 and GRADE were used to assess the quality of the included articles. Diagnostic data were pooled based on three cutpoints: lowest and optimal, as chosen by study authors, and manufacturers’ suggested. The effect of various determinants (e.g., age, gender, BMI, and renal function) on diagnostic performance was also investigated. Pooled sensitivity and specificity of BNP and NT-proBNP using the lowest [0.85 (sensitivity) and 0.54 (specificity)], optimal (0.80 and 0.61), and manufacturers’ (0.74 and 0.67) cutpoints showed good performance for diagnosing HF. Similar performance was seen for NT-proBNP: lowest (0.90 and 0.50), optimal (0.86 and 0.58), and manufacturers’ (0.82 and 0.58) cutpoints. Overall, we rated the strength of evidence as high because further studies will be unlikely to change the estimates diagnostic performance.