A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow)

Background: Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections. Methods: Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures. Results: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported. Conclusion: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

Placebo Response of Non-Pharmacological and Pharmacological Trials in Major Depression: A Systematic Review and Meta-Analysis

Background: Although meta-analyses have shown that placebo responses are large in Major Depressive Disorder (MDD) trials; the placebo response of devices such as repetitive transcranial magnetic stimulation (rTMS) has not been systematically assessed. We proposed to assess placebo responses in two categories of MDD trials: pharmacological (antidepressant drugs) and non-pharmacological (device-rTMS) trials. Methodology/Principal Findings: We performed a systematic review and meta-analysis of the literature from April 2002 to April 2008, searching MEDLINE, Cochrane, Scielo and CRISP electronic databases and reference lists from retrieved studies and conference abstracts. We used the keywords placebo and depression and escitalopram for pharmacological studies; and transcranial magnetic stimulation and depression and sham for non-pharmacological studies. All randomized, double-blinded, placebo-controlled, parallel articles on major depressive disorder were included. Forty-one studies met our inclusion criteria-29 in the rTMS arm and 12 in the escitalopram arm. We extracted the mean and standard values of depression scores in the placebo group of each study. Then, we calculated the pooled effect size for escitalopram and rTMS arm separately, using Cohen's d as the measure of effect size. We found that placebo response are large for both escitalopram (Cohen's d-random-effects model-1.48; 95% C.I. 1.26 to 1.6) and rTMS studies (0.82; 95% C.I. 0.63 to 1). Exploratory analyses show that sham response is associated with refractoriness and with the use of rTMS as an add-on therapy, but not with age, gender and sham method utilized. Conclusions/Significance: We confirmed that placebo response in MDD is large regardless of the intervention and is associated with depression refractoriness and treatment combination (add-on rTMS studies). The magnitude of the placebo response seems to be related with study population and study design rather than the intervention itself.

Systematic review and cladistic analysis of the genus Eusarcus Perty 1833 (Arachnida, Opiliones, Gonyleptidae)

Eusarcus Perty 1833 is one of the oldest described genera of Pachylinae, comprising 36 species distributed from northeastern to southern Brazil (including the central west region), northeastern Argentina, eastern Paraguay and Uruguay. The genus is reviewed and a new classification is proposed based on a cladistic analysis. A cladistic analysis was performed with the 34 valid species of Eusarcus and 11 species belonging to certain Gonyleptidae subfamilies. The data matrix has 67 characters: 14 from dorsal scutum and pedipalp, 38 from male legs and 15 from male genitalia. Two equally parsimonious trees were found (L=319; C. I.=0.26, R. I.=0.61). Pygophalangodus gemignanii uruguayensis Ringuelet 1955a and Pygophalangodus gemignanii gemignanii Mello-Leitao 1931b are here elevated to the category of species, and the following new combinations are proposed: E. catharinensis (Mello-Leitao 1927); E. berlae (Mello-Leitao 1932); E. gemignanii (Mello-Leitao 1931b); E. signatus(Roewer 1949); E. sooretamae (Soares & Soares 1946a); E. uruguayensis (Ringuelet 1955a). The following generic synonymies are proposed: Eusarcus Perty 1833 (type species E. armatus Perty 1833) = Metagraphinotus Mello-Leitao 1927 (type species M. catharinensis Mello-Leitao 1927), Pareusarcus Roewer 1929 (type species P. corniculatus Roewer 1929), Pygophalangodus Mello-Leitao 1931b (type species P. gemignanii-gemignanii Mello-Leitao 1931b) and Antetriceras Roewer 1949 (type species A. signatus Roewer 1949). The following specific synonymies are proposed: Eusarcus hastatus Sorensen 1884 = Pucrolioides argentina Roewer 1913, E. guimaraensi H. Soares 1945, Jacarepaguana pectinifemur Piza 1943, Canestrinia canalsi Mello-Leitao 1931a, and E. maquinensis H. Soares 1966b; E. armatus Perty 1833 = E. curvispinosus Mello-Leitao 1923b, and Enantiocentron montis Mello-Leitao 1936; Eusarcus catharinensis (Mello-Leitao 1927) = E. antoninae Mello-Leitao 1936, E. perpusillus Mello-Leitao 1945, E. tripos Mello-Leitao 1940, and Metagraphinotus trochanterspinosus Soares & Soares 1947b; E. nigrimaculatus Mello-Leitao 1924 = Pareusarcus centromelos Mello-Leitao 1935a, E. furcatus Roewer 1929, Orguesia armata Roewer 1913, and Pareusarcus corniculatus Roewer 1929; E. oxyacanthus Kollar in Koch 1839a = Enantiocentron doriphorus Mello-Leitao 1932, and E. spinimanu Mello-Leitao 1932; E. pusillus Sorensen 1884 = E. vervloeti B. Soares 1944c; E. berlae Mello-Leitao 1932 = Metagraphinotus arlei Mello-Leitao 1935a. Metapucrolia armata (Sorensen 1895) is revalidated, transferred to Eusarcus and considered as a species inquirenda. A new name, Eusarcus metapucrolia is proposed for this species to avoid homonymy with the type species of Eusarcus, E. armatus Perty 1833. Eusarcus aberrans Mello-Leitao 1939a is considered as a species inquirenda. The male of E. teresincola Soares & Soares 1946a is described. Female of the following species are described: E. bifidus Roewer 1929; E. dubius B. Soares 1943b; E. insperatus B. Soares 1944a; E. schubarti Soares & Soares 1946a; E. sooretamae (Soares & Soares 1946a). The following new species are described from Brazil: E. acrophthalmus (type locality: Bahia, Ilheus, Parataquice); E. alpinus (Rio de Janeiro, Santa Maria Madalena, Parque Estadual do Desengano); E. caparaoensis (Minas Gerais, Alto Caparao, Parque Nacional do Caparao); E. cavernicola (Goias, Sao Domingos, Parque Estadual de Terra Ronca, Lapa da Angelica); E. didactylus (Rio de Janeiro, Teresopolis, Parque Nacional Serra dos Orgaos); E. garibaldiae (Santa Catarina, Itajai); E. geometricus (Rio de Janeiro, Teresopolis, Parque Nacional Serra dos Orgaos); E. manero (Rio de Janeiro, Marica, Itaipuacu); E. matogrossensis (Mato Grosso, Chapada dos Guimaraes); E. mirabilis (Minas Gerais, Marlieria, Parque Estadual Rio Doce); E. sergipanus (Sergipe, Itabaiana, Parque Nacional de Itabaiana) and E. tripectinatus (Minas Gerais, Rio Preto). The holotype of E. curvispinosus is proposed as the neotype of E. armatus Perty 1833, the type material of which has been lost. Lectotypes for the following species were designated: E. aduncus; E. hastatus; E. oxyacanthus.

The treatment of tardive dyskinesia: A systematic review and meta-analysis

This systematic review aimed to collate randomized controlled trials (RCTs) of various interventions used to treat tardive dyskinesia (TD) and, where appropriate, to combine the data for mete-analysis, Clinical trials were identified by electronic searches, handsearches and contact with principal investigators. Data were extracted independently by two reviewers, for outcomes related to improvement, deterioration, side-effects and drop out rates. Data were pooled using the Mantel-Haenzel Odds Ratio (fixed effect model). For treatments that had significant effects, the number needed to treat (NNT) was calculated. From 296 controlled clinical trials, data were extracted from 47 trials. For most interventions, we could identify no RCT-derived evidence of efficacy. A meta-analysis showed that baclofen, deanol and diazepam were no more effective than a placebo. Single RCTs demonstrated a lack of evidence of any effect for bromocriptine, ceruletide, clonidine, estrogen, gamma linolenic acid, hydergine, lecithin, lithium, progabide, seligiline and tetrahydroisoxazolopyridinol. The meta-analysis found that five interventions were effective: L-dopa, oxypertine, sodium valproate, tiapride and vitamin E; neuroleptic reduction was marginally significant. Data from single RCTs revealed that insulin, alpha methyl dopa and reserpine were more effective than a placebo. There was a significantly increased risk of adverse events associated with baclofen, deanol, L-dopa, oxypertine and reserpine. Metaanalysis of the impact of placebo (n=485) showed that 37.3% of participants showed an improvement. Interpretation of this systematic review requires caution as the individual trials identified tended to have small sample sizes. For many compounds, data from only one trial were available, and where meta-analyses were possible, these were based on a small number of trials. Despite these concerns, the review facilitated the interpretation of the large and diverse range of treatments used for TD. Clinical recommendations for the treatment of TD are made, based on the availability of RCT-derived evidence, the strength of that evidence and the presence of adverse effects. (C) 1999 Elsevier Science B.V. All rights reserved.

Suicide and recency of health care contacts - A systematic review

Background Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play. Method Asystematic review of the literature. Results Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up-to 9% may commit suicide within one day of discharge. The corresponding figures are I I and 4% for community-based psychiatric care and 83 and 20% for general practitioners. Conclusions Among those who die by suicide. contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Applying the results of a systematic review in general practice

Objective: To assess how general practitioners might interpret and apply the results of a systematic review relevant to general practice. Design: Cross-sectional postal survey of general practitioners in August 1997. Participants: 51 general practitioners in the Southern Division of General Practice in Adelaide and 11 professors or heads of departments of general practice. Main outcome measures:Extent to which comments on the implications for practice and implications for research coincided with the evidence presented in a systematic review of antibiotics for the treatment of acute otitis media in children; and reported probability that respondents would prescribe antibiotics in three brief case scenarios. Results: There was considerable variation in the comments made by general practitioners on the implications of the review for clinical practice. After reading the review, respondents with training in critical appraisal were more likely to state that children with acute otitis media would usually recover spontaneously and reported a lower probability of prescribing antibiotics in two of the three case scenarios. Conclusions: Providing systematic reviews is not sufficient for the results of such evidence to be translated:into clinical practice. There is an association between critical appraisal skills and the application of evidence-based practice.

Effect of coinfection with STDs and of STD treatment on HIV shedding in genital-tract secretions - Systematic review and data synthesis

Objective: To determine whether coinfection with sexually transmitted diseases (STD) increases HIV shedding in genital-tract secretions, and whether STD treatment reduces this shedding. Design: Systematic review and data synthesis of cross-sectional and cohort studies meeting. predefined quality criteria. Main Outcome Measures: Proportion of patients with and without a STD who had detectable HIV in genital secretions, HIV toad in genital secretions, or change following STD treatment. Results: Of 48 identified studies, three cross-sectional and three cohort studies were included. HIV was detected significantly more frequently in participants infected with Neisseria gonorrhoeae (125 of 309 participants, 41%) than in those without N gonorrhoeae infection (311 of 988 participants, 32%; P = 0.004). HIV was not significantly more frequently detected in persons infected with Chlamydia trachomatis (28 of 67 participants, 42%) than in those without C trachomatis infection (375 of 1149 participants, 33%; P = 0.13). Median HIV load reported in only one study was greater in men with urethritis (12.4 x 10(4) versus 1.51 x 10(4) copies/ml; P = 0.04). In the only cohort study in which this could be fully assessed, treatment of women with any STD reduced the proportion of those with detectable HIV from 39% to 29% (P = 0.05), whereas this proportion remained stable among controls (15-17%), A second cohort study reported fully on HIV load; among men with urethritis, viral load fell from 12.4 to 4.12 x 10(4) copies/ml 2 weeks posttreatment, whereas viral load remained stable in those without urethritis. Conclusion: Few high-quality studies were found. HIV is detected moderately more frequently in genital secretions of men and women with a STD, and HIV load is substantially increased among men with urethritis, Successful STD treatment reduces both of these parameters, but not to control levels. More high-quality studies are needed to explore this important relationship further.

Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and other sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women

We aimed to determine the effectiveness of the vaginally administered spermicide nonoxynol-9 (N-9) among women for the prevention of HIV and other sexually transmitted infections (STIs), We did a systematic review of randomised controlled trials, Nine such trials including 5096 women, predominantly sex workers, comparing N-9 with placebo or no treatment, were included. Primary outcomes were new HIV infection, new episodes of various STIs, and genital lesions. Five trials included HIV and nine included STI outcomes, and all but one (2% of the data) contributed to the meta-analysis. Overall, relative risks of HIV infection (1.12, 95% confidence interval 0.88-1.42), gonorrhoea (0.91, 0.67-1.24), chlamyclia (0.88, 0.77-1.01), cervical infection (1.01, 0.84-1-22), trichomoniasis (0.84, 0.69-1.02), bacterial vaginosis (0.88, 0.74-1.04) and candidiasis (0.97, 0.84-1.12) were not significantly different in the N-9 and placebo or no treatment groups. Genital lesions were more common in the N-9 group (1.18, 1.02-1.36). Our review has found no statistically significant reduction in risk of HIV and STIs, and the confidence intervals indicate that any protection that may exist is likely to be very small. There is some evidence of harm through genital lesions. N-9 cannot be recommended for HIV and STI prevention.

Systematic review: Terlipressin in acute oesophageal variceal haemorrhage

Background: Controversy exists surrounding pharmacological therapy in acute variceal bleeding. Methods: To determine the efficacy and safety of terlipressin. Methods: Randomized trials were identified and duplicate, independent, review identified 20 randomized trials involving 1609 patients that compared terlipressin with placebo, balloon tamponade, endoscopic treatment, octreotide, somatostatin or vasopressin for treatment of acute oesophageal variceal haemorrhage. Results: Meta-analysis showed that compared to placebo, terlipressin reduced mortality (relative risk 0.66, 95% CI 0.49-0.88), failure of haemostasis (relative risk 0.63, 95% CI 0.45-0.89) and the number of emergency procedures per patient required for uncontrolled bleeding or rebleeding (relative risk 0.72, 95% CI 0.55-0.93). When used as an adjuvant to endoscopic sclerotherapy, terlipressin reduced failure of haemostasis (relative risk 0.75, 95% CI 0.58-0.96), and had an effect on reducing mortality that approached statistical significance (relative risk 0.74, 95% CI 0.53-1.04). No significant difference was demonstrated between terlipressin and endoscopic sclerotherapy, balloon tamponade, somatostatin or vasopressin. Haemostasis was achieved more frequently with octreotide compared to terlipressin (relative risk 1.62, 95% CI 1.05-2.50), but this result was based on unblinded studies. Adverse events were similar between terlipressin and the other comparison groups except for vasopressin, which caused more withdrawals due to adverse events. Conclusions: Terlipressin is a safe and effective treatment for acute oesophageal variceal bleeding, with or without adjuvant endoscopic sclerotherapy. Terlipressin appears to reduce mortality in acute oesophageal variceal bleeding compared to placebo, and is the only pharmacological agent shown to do so. Future studies will be required to detect potential mortality differences between terlipressin and other therapeutic approaches.

The incidence of schizophrenia: A systematic review

There has been a debate on whether or not the incidence of schizophrenia varies across time and place. In order to optimise the evidence upon which this debate is based, we have undertaken a systematicsystematic review of the literature. In this paper we provide an overview of the methods of the review and a preliminary analysis of the studies identified to date. Electronic databases (Medline, Psychlnfo, Embase, LILAC) were systematically searched for articles published between January 1965 and December 2001. The search terms were: (schizo* OR psycho*)AND (incidence OR prevalence). References were also identified from review articles, reference list and by writing to authors. To date we have identified 137 papers drawn from 33 nations. 37 papers in language other than English await translation. The currently included papers have generated 1413 different items of rate information data. In order to analyze these data we have undertaken several sequential filters in order to identify (a) non-overlapping data, (b) birth cohort study versus noncohort studies, (c) overall and sex-specific rates, (d) diagnostic criteria, (e) age ranges, (f) epoch of study, and (g) data on migrant or other special interest groups. In addition, we will examine the impact of urbanicity of site, age and/or sex standardization, and quality score on the incidence rates. The various discrete incidence rates will be presented graphically and the impact of various filters on these rates will be inspected using meta-analytic techniques. The use of meta-analysis may help elucidate the epidemiological landscape with respect to the incidence of schizophrenia and aid in the generation of new hypothesis. Acknowledgements: The Stanley Medical Research Institute supported project

Whispered voice test for screening for hearing impairment in adults and children: systematic review

Objective To determine the accuracy of the whispered voice test in detecting hearing impairment in adults and children. Design Systematic review of studies of test accuracy. Data sources Medline, Embase, Science Citation Index, unpublished theses, manual searching of bibliographies of known primary and review articles, and contact with authors. Study selection Two reviewers independently selected and extracted data on study characteristics, quality, and accuracy of studies. Studies were included if they had cross sectional designs, at least one of the index tests was the whispered voice test, and the reference test (audiometry) was performed on at least 80% of the participants. Data extraction Data were used to form 2x2 contingency tables with hearing impairment by audiometry as the reference standard. Data synthesis The eight studies that were found used six different techniques. The sensitivity in the four adult studies was 90% or 100% and the specificity was 70% to 87%. The sensitivity in the four childhood studies ranged from 80% to 96% and specificity ranged from 90% to 98%. Conclusion The whispered voice test is a simple and accurate test for detecting hearing impairment. There is some concern regarding the lower sensitivity in children and the overall reproducibility of the test, particularly in primary care settings. Further studies should be conducted in primary care settings to explore the influence of components of the testing procedure to optimise test sensitivity and to promote standardisation of the testing procedure.