British Medical Journal: 08/12/2007 – Vol.335 Num.7631


[RESEARCH] New point of care Chlamydia Rapid Test bridging the gap between diagnosis and treatment: performance evaluation study

Objective To evaluate the performance of a new Chlamydia Rapid Test with vaginal swab specimens as a potential tool for chlamydia diagnosis and screening.

Design Performance evaluation study.

Settings A young people’s sexual health centre (site 1) and two genitourinary medicine clinics (sites 2 and 3) in the United Kingdom.

Participants 1349 women aged between 16 and 54 attending one of the three clinics.

Main outcome measures Sensitivity, specificity, positive predictive value, and negative predictive value of the Chlamydia Rapid Test versus polymerase chain reaction and strand displacement amplification assays; correlation between the Chlamydia Rapid Test visual signal and organism load; acceptability to participants of self collected vaginal swabs as the specimen type for Chlamydia testing.

Results Polymerase chain reaction positivity rates for Chlamydia trachomatis infection were 8.4% (56/663) at site 1, 9.4% (36/385) at site 2, and 6.0% (18/301) at site 3. Compared with polymerase chain reaction assay, the resolved sensitivity, specificity, positive predictive value, and negative predictive value of the Chlamydia Rapid Test were 83.5% (91/109), 98.9% (1224/1238), 86.7% (91/105), and 98.6% (1224/1242). Compared with strand displacement amplification assay, sensitivity and specificity of the Chlamydia Rapid Test were 81.6% (40/49) and 98.3% (578/588). Organism load of self collected vaginal swabs ranged from 5.97×102 to 1.09×109 Chlamydia plasmids per swab, which correlated well with the Chlamydia Rapid Test’s visual signal (r=0.6435, P<0.0001). Most (95.9%) surveyed participants felt comfortable about collecting their own swabs.

Conclusions The performance of the Chlamydia Rapid Test with self collected vaginal swabs indicates that it would be an effective same day diagnostic and screening tool for Chlamydia infection in women. The availability of Chlamydia Rapid Test results within 30 minutes allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. It could also provide a simple and reliable alternative to nucleic acid amplification tests in chlamydia screening programmes.
[RESEARCH] Long term pharmacotherapy for obesity and overweight: updated meta-analysis

Objective To summarise the long term efficacy of anti-obesity drugs in reducing weight and improving health status.

Design Updated meta-analysis of randomised trials.

Data sources Medline, Embase, the Cochrane controlled trials register, the Current Science meta-register of controlled trials, and reference lists of identified articles. All data sources were searched from December 2002 (end date of last search) to December 2006.

Studies reviewed Double blind randomised placebo controlled trials of approved anti-obesity dugs used in adults (age over 18) for one year or longer.

Results 30 trials of one to four years’ duration met the inclusion criteria: 16 orlistat (n=10 631 participants), 10 sibutramine (n=2623), and four rimonabant (n=6365). Of these, 14 trials were new and 16 had previously been identified. Attrition rates averaged 30-40%. Compared with placebo, orlistat reduced weight by 2.9 kg (95% confidence interval 2.5 kg to 3.2 kg), sibutramine by 4.2 kg (3.6 kg to 4.7 kg), and rimonabant by 4.7 kg (4.1 kg to 5.3 kg). Patients receiving active drug treatment were significantly more likely to achieve 5% and 10% weight loss thresholds. Orlistat reduced the incidence of diabetes and improved concentrations of total cholesterol and low density lipoprotein cholesterol, blood pressure, and glycaemic control in patients with diabetes but increased rates of gastrointestinal side effects and slightly lowered concentrations of high density lipoprotein. Sibutramine lowered concentrations of high density lipoprotein cholesterol and triglycerides but raised blood pressure and pulse rate. Rimonabant improved concentrations of high density lipoprotein cholesterol and triglycerides, blood pressure, and glycaemic control in patients with diabetes but increased the risk of mood disorders.

Conclusions Orlistat, sibutramine, and rimonabant modestly reduce weight, have differing effects on cardiovascular risk profiles, and have specific adverse effects.
[RESEARCH] Mortality in men admitted to hospital with acute urinary retention: database analysis

Objectives To investigate mortality in men admitted to hospital with acute urinary retention and to report on the effects of comorbidity on mortality.

Design Analysis of the hospital episode statistics database linked to the mortality database of the Office for National Statistics.

Setting NHS hospital trusts in England, 1998-2005.

Participants All men aged over 45 who were admitted to NHS hospitals in England with a first episode of acute urinary retention.

Main outcome measures Mortality in the first year after acute urinary retention and standardised mortality ratio against the general population.

Results During the study period, 176 046 men aged over 45 were admitted to hospital with a first episode of acute urinary retention. In 100 067 men with spontaneous acute urinary retention, the one year mortality was 4.1% in men aged 45-54 and 32.8% in those aged 85 and over. In 75 979 men with precipitated acute urinary retention, mortality was 9.5% and 45.4%, respectively. In men with spontaneous acute urinary retention aged 75-84, the most prevalent age group, the one year mortality was 12.5% in men without comorbidity and 28.8% in men with comorbidity. The corresponding figures for men with precipitated acute urinary retention were 18.1% and 40.5%. Compared with the general population, the highest relative increase in mortality was in men aged 45-54 (standardised mortality ratio 10.0 for spontaneous and 23.6 for precipitated acute urinary retention) and the lowest for men 85 and over (1.7 and 2.4, respectively).

Conclusions Mortality in men admitted to hospital with acute urinary retention is high and increases strongly with age and comorbidity. Patients might benefit from multi-disciplinary care to identify and treat comorbid conditions.
[RESEARCH] Financial ties and concordance between results and conclusions in meta-analyses: retrospective cohort study

Objective To determine whether financial ties to one drug company are associated with favourable results or conclusions in meta-analyses on antihypertensive drugs.

Design Retrospective cohort study.

Setting Meta-analyses published up to December 2004 that were not duplicates and evaluated the effects of antihypertensive drugs compared with any comparator on clinical end points in adults. Financial ties were categorised as one drug company compared with all others.

Main outcome measures The main outcomes were the results and conclusions of meta-analyses, with both outcomes separately categorised as being favourable or not favourable towards the study drug. We also collected data on characteristics of meta-analyses that the literature suggested might be associated with favourable results or conclusions.

Results 124 meta-analyses were included in the study, 49 (40%) of which had financial ties to one drug company. On univariate logistic regression analyses, meta-analyses of better methodological quality were more likely to have favourable results (odds ratio 1.16, 95% confidence interval 1.07 to 1.27). Although financial ties to one drug company were not associated with favourable results, such ties constituted the only characteristic significantly associated with favourable conclusions (4.09, 1.30 to 12.83). When controlling for other characteristics of meta-analyses in multiple logistic regression analyses, meta-analyses that had financial ties to one drug company remained more likely to report favourable conclusions (5.11, 1.54 to 16.92).

Conclusion Meta-analyses on antihypertensive drugs and with financial ties to one drug company are not associated with favourable results but are associated with favourable conclusions.
[CLINICAL REVIEW] Medical aspects of male circumcision

[PRACTICE] Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital

Problem In-hospital cardiac arrest often represents failure of optimal clinical care. The use of medical emergency teams to prevent such events is controversial. In-hospital cardiac arrests have been reduced in several single centre historical control studies, but the only randomised prospective study showed no such benefit. In our hospital an important problem was failure to call the medical emergency team or cardiac arrest team when, before in-hospital cardiac arrest, patients had fulfilled the criteria for calling the team.

Design Single centre, prospective audit of cardiac arrests and data on use of the medical emergency team during 2000 to 2005.

Setting 400 bed general outer suburban metropolitan teaching hospital.

Strategies for change Three initiatives in the hospital to improve use of the medical emergency team: orientation programme for first year doctors, professional development course for medical registrars, and the evolving role of liaison intensive care unit nurses.

Key measures for improvement Incidence of cardiac arrests.

Effects of the change Incidence of cardiac arrests decreased 24% per year, from 2.4/1000 admissions in 2000 to 0.66/1000 admissions in 2005.

Lessons learnt Medical emergency teams can be efficacious when supported with a multidisciplinary, multifaceted education system for clinical staff.

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