Significant Treatment Effect In Favour Research Articles

WITHDRAWN: Gluten- and casein-free diets for autistic spectrum disorder.

It has been suggested that peptides from gluten and casein may have a role in the origins of autism and that the physiology and psychology of autism might be explained by excessive opioid activity linked to these peptides. Research has reported abnormal levels of peptides in the urine and cerebrospinal fluid of people with autism. To determine the efficacy of gluten and/or casein free diets as an intervention to improve behaviour, cognitive and social functioning in individuals with autism. The following electronic databases were searched: CENTRAL(The Cochrane Library Issue 2, 2007), MEDLINE (1966 to April 2007), PsycINFO (1971 to April 2007), EMBASE (1974 to April 2007), CINAHL (1982 to April 2007), ERIC (1965 to 2007), LILACS (1982 to April 2007), and the National Research register 2007 (Issue1). Review bibliographies were also examined to identify potential trials. All randomised controlled trials (RCT) involving programmes which eliminated gluten, casein or both gluten and casein from the diets of individuals diagnosed with an autistic spectrum disorder. Abstracts of studies identified in searches of electronic databases were assessed to determine inclusion by two independent authors The included trials did not share common outcome measures and therefore no meta-analysis was possible. Data are presented in narrative form. Two small RCTs were identified (n = 35). No meta-analysis was possible. There were only three significant treatment effects in favour of the diet intervention: overall autistic traits, mean difference (MD) = -5.60 (95% CI -9.02 to -2.18), z = 3.21, p=0.001 (Knivsberg 2002) ; social isolation, MD = -3.20 (95% CI -5.20 to 1.20), z = 3.14, p = 0.002) and overall ability to communicate and interact, MD = 1.70 (95% CI 0.50 to 2.90), z = 2.77, p = 0.006) (Knivsberg 2003). In addition three outcomes showed no significant difference between the treatment and control group and we were unable to calculate mean differences for ten outcomes because the data were skewed. No outcomes were reported for disbenefits including harms. Research has shown of high rates of use of complementary and alternative therapies (CAM) for children with autism including gluten and/or casein exclusion diets. Current evidence for efficacy of these diets is poor. Large scale, good quality randomised controlled trials are needed.

Pharmacological Therapy for Apathy in Alzheimer's Disease: A Systematic Review and Meta-Analysis.

Apathy is highly prevalent in Alzheimer's disease (AD), but whether pharmacotherapy is effective in managing apathy is unclear. To assess the efficacy of pharmacotherapy for apathy in AD we searched for randomized controlled trials (RCT) and aggregate data reporting on apathy in several search engines, reference lists of articles, and reviews. Demographic characteristics and relevant data were extracted to assess apathy. Fifteen RCTs' were examined, and 11 were used in aggregate meta-analytic statistics. Drugs included were cholinesterase inhibitors, memantine, and psycho-stimulants. We found no significant treatment effect in favour of any of the drugs, and the effect-size estimates under a random effect model were heterogeneous. Most RCTs had a high attrition rate and used the NPI apathy subscale to measure apathy. The lack of an effect could be explained by methodological limitations, publication bias, and heterogeneity.

Aromatherapy for dementia

Complementary therapy has received great interest within the field of dementia treatment and the use of aromatherapy and essential oils is increasing. In a growing population where the majority of patients are treated by US Food and Drug Administration (FDA)-approved drugs, the efficacy of treatment is short term and accompanied by negative side effects. Utilisation of complimentary therapies in dementia care settings presents as one of few options that are attractive to practitioners and families as patients often have reduced insight and ability to verbally communicate adverse reactions. Amongst the most distressing features of dementia are the behavioural and psychological symptoms. Addressing this facet has received particular interest in aromatherapy trials, with a shift in focus from reducing cognitive dysfunction to the reduction of behavioural and psychological symptoms in dementia. To assess the efficacy of aromatherapy as an intervention for people with dementia. ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, was searched on 26 November 2012 and 20 January 2013 using the terms: aromatherapy, lemon, lavender, rose, aroma, alternative therapies, complementary therapies, essential oils. All relevant randomised controlled trials were considered. A minimum length of a trial and requirements for follow-up were not included, and participants in included studies had a diagnosis of dementia of any type and severity. The review considered all trials using fragrance from plants defined as aromatherapy as an intervention with people with dementia and all relevant outcomes were considered. Titles and abstracts extracted by the searches were screened for their eligibility for potential inclusion in the review. For Burns 2011, continuous outcomes were estimated as the mean difference between groups and its 95% confidence interval using a fixed-effect model. For Ballard 2002, analysis of co-variance was used for all outcomes, with the nursing home being treated as a random effect. Seven studies with 428 participants were included in this review; only two of these had published usable results. Individual patient data were obtained from one trial (Ballard 2002) and additional analyses performed. The additional analyses conducted using individual patient data from Ballard 2002 revealed a statistically significant treatment effect in favour of the aromatherapy intervention on measures of agitation (n = 71, MD -11.1, 95% CI -19.9 to -2.2) and behavioural symptoms (n = 71, MD -15.8, 95% CI -24.4 to -7.2). Burns 2011, however, found no difference in agitation (n = 63, MD 0.00, 95% CI -1.36 to 1.36), behavioural symptoms (n = 63, MD 2.80, 95% CI -5.84 to 11.44), activities of daily living (n = 63, MD -0.50, 95% CI -1.79 to 0.79) and quality of life (n = 63, MD 19.00, 95% CI -23.12 to 61.12). Burns 2011 and Fu 2013 found no difference in adverse effects (n = 124, RR 0.97, 95% CI 0.15 to 6.46) when aromatherapy was compared to placebo. The benefits of aromatherapy for people with dementia are equivocal from the seven trials included in this review. It is important to note there were several methodological difficulties with the included studies. More well-designed, large-scale randomised controlled trials are needed before clear conclusions can be drawn regarding the effectiveness of aromatherapy for dementia. Additionally, several issues need to be addressed, such as whether different aromatherapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.

Year in review 2013: Lung cancer, respiratory infections, tuberculosis, cystic fibrosis, pleural diseases, bronchoscopic intervention and imaging

This Year in Review examines the most relevant articles published on lung cancer, respiratory infections, tuberculosis (TB), cystic fibrosis (CF), pleural diseases, and interventional pulmonology and imaging in Respirology and other respiratory medicine journals during 2013. Important findings are highlighted with comments in the following sections, each of which was contributed by an author as named in the beginning of each section.

Effects of neck coordination exercise on sensorimotor function in chronic neck pain: a randomized controlled trial.

To evaluate the effect of neck coordination exercise on sensorimotor function in women with neck pain compared with best-available treatment and sham treatment. Observer-blinded randomized controlled trial with short-term and 6-month follow-ups. Women with chronic non-specific neck pain were randomized to 3 groups: neck coordination exercise with a novel training device; strength training for the neck and shoulders; or massage. Each group had 36 participants. The intervention period was 11 weeks with 22 individually supervised sessions. Primary outcomes were postural sway measures and precision of goal-directed arm movements. Secondary outcomes were range of motion for the neck, peak speed of axial rotation, and neck pain. A repeated measures multivariate analysis of variance (MANOVA) was conducted separately on the primary outcomes for the short-term and 6-month evaluations and on the sensorimotor secondary outcomes for the 6-month effect. The 6-month effect on pain was analysed with a repeated measures analysis of variance (ANOVA). No significant treatment effects in favour of neck coordination exercise were found for short-term or 6-month evaluations. Neck coordination exercise is no better than strength training and massage in improving sensorimotor function. Further research should investigate the use of cut-offs for sensorimotor dysfunctions prior to proprioceptive or coordinative training.

Self-management programmes for people post stroke: a systematic review

Objective: To examine the evidence base underlying self-management programmes specific to stroke survivors. Data sources: Eleven electronic databases were searched using combinations of keywords related to stroke and self-management. Review methods: Studies involving adults with a clinical diagnosis of stroke, which explored self-management interventions, were included. Study selection was verified by two reviewers who independently conducted methodological quality appraisal and data extraction using a tool developed by The American Academy for Cerebral Palsy and Developmental Medicine. Results: Fifteen studies were included in this review. Significant treatment effects in favour of the self-management intervention were found in six out of nine randomized controlled trials, and three out of six non-randomized trials in our review. Four randomized controlled trials involving more than 100 participants per trial reported statistically significant results in favour of the self-management group in relation to measures of disability, confidence in recovery, the stroke specific quality of life (sub-scales of family roles and fine motor tasks), and the physical component scale of the short form SF-36 Score. The wide range of outcome measures used prevented comparison across studies. Conclusions: This review provides some preliminary support for the potential importance of self-management interventions after stroke. The most appropriate content and best approach for delivery of these interventions remains to be determined. Further high-quality randomized controlled trials are needed to test the feasibility, acceptability, and efficacy of stroke self-management programmes.

Pressure-relieving interventions for treating diabetic foot ulcers

Diabetes-related foot ulceration is a major contributor to morbidity in diabetes. Diabetic foot ulcers are partly a consequence of abnormal foot pressures and pressure relief is a widely used treatment for healing diabetes-related plantar foot ulcers, but the most effective method for healing is unclear. To determine the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. For this update we searched the Cochrane Wounds Group Specialised Register (searched 2 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to October Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, October 31, 2012); Ovid EMBASE (1980 to 2012 Week 43); and EBSCO CINAHL (1982 to 1 November 2012). There were no restrictions based on language or publication status. Randomised controlled trials evaluating the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. Data from eligible trials were extracted, and summarised using a data extraction sheet, by two review authors independently. Fourteen trials (709 participants) met the inclusion criteria for the review. One study compared two different types of non-removable casts with no discernable difference between the groups. Seven studies (366 participants) compared non-removable casts with removable pressure-relieving devices. In five of those studies non-removable casts were associated with a statistically significant increase in the number of ulcers healed compared with the removable device (RR 1.17 95% CI 1.01 to 1.36: P value = 0.04).Two studies (98 participants) found that significantly more ulcers healed with non-removable casts than with dressings alone. Achilles tendon lengthening combined with a non-removable cast in one study resulted in significantly more healed ulcers at 7 months than non-removable cast alone (RR 2.23; 95% CI 1.32 to 3.76). More ulcers remained healed at two years in this group (RR 3.41; 95% CI 1.42 to 8.18).Other comparisons included surgical debridement of ulcers; felt fitted to the foot; felted foam dressings and none of these showed a statistically significant treatment effect in favour of the intervention. Non-removable, pressure-relieving casts are more effective in healing diabetes related plantar foot ulcers than removable casts, or dressings alone. Non-removable devices, when combined with Achilles tendon lengthening were more successful in one forefoot ulcer study than the use of a non-removable cast alone.

A mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: a randomised controlled trial

ObjectiveTo evaluate the effects of a mindfulness-based group intervention, the Vitality Training Programme (VTP), in adults with inflammatory rheumatic joint diseases.MethodsIn a randomised controlled trial, the VTP—a 10-session mindfulness-based group...

Gluten- and casein-free diets for autistic spectrum disorder

It has been suggested that peptides from gluten and casein may have a role in the origins of autism and that the physiology and psychology of autism might be explained by excessive opioid activity linked to these peptides. Research has reported abnormal levels of peptides in the urine and cerebrospinal fluid of people with autism. To determine the efficacy of gluten and/or casein free diets as an intervention to improve behaviour, cognitive and social functioning in individuals with autism. The following electronic databases were searched: CENTRAL(The Cochrane Library Issue 2, 2007), MEDLINE (1966 to April 2007), PsycINFO (1971 to April 2007), EMBASE (1974 to April 2007), CINAHL (1982 to April 2007), ERIC (1965 to 2007), LILACS (1982 to April 2007), and the National Research register 2007 (Issue1). Review bibliographies were also examined to identify potential trials. All randomised controlled trials (RCT) involving programmes which eliminated gluten, casein or both gluten and casein from the diets of individuals diagnosed with an autistic spectrum disorder. Abstracts of studies identified in searches of electronic databases were assessed to determine inclusion by two independent authors The included trials did not share common outcome measures and therefore no meta-analysis was possible. Data are presented in narrative form. Two small RCTs were identified (n = 35). No meta-analysis was possible. There were only three significant treatment effects in favour of the diet intervention: overall autistic traits, mean difference (MD) = -5.60 (95% CI -9.02 to -2.18), z = 3.21, p=0.001 (Knivsberg 2002) ; social isolation, MD = -3.20 (95% CI -5.20 to 1.20), z = 3.14, p = 0.002) and overall ability to communicate and interact, MD = 1.70 (95% CI 0.50 to 2.90), z = 2.77, p = 0.006) (Knivsberg 2003). In addition three outcomes showed no significant difference between the treatment and control group and we were unable to calculate mean differences for ten outcomes because the data were skewed. No outcomes were reported for disbenefits including harms. Research has shown of high rates of use of complementary and alternative therapies (CAM) for children with autism including gluten and/or casein exclusion diets. Current evidence for efficacy of these diets is poor. Large scale, good quality randomised controlled trials are needed.

Aroma therapy for dementia.

Complementary therapies have become more commonly used over the last decade and have been applied to a range of health problems, including dementia. Of these, aroma therapy is reported to be the most widely used in the British National Health Service (Lundie 1994) and might be of use for people with dementia for whom verbal interaction may be difficult and conventional medicine of only marginal benefit. Aroma therapy has been used for people with dementia to reduce disturbed behaviour (e.g. Brooker 1997), promote sleep (e.g. Wolfe 1996), and stimulate motivational behaviour (e.g. MacMahon 1998). To assess the efficacy of aroma therapy as an intervention for people with dementia. The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched on 29 October 2002 to find all relevant trials using the terms: aroma therap*, "aroma therap*", "complementary therap*", "alternative therap*" and "essential oil". The CDCIG Register contains records from all major health care databases and is updated regularly. Additionally, relevant journals were hand searched, and 'experts' in the field of complementary therapies and dementia contacted. All relevant randomized controlled trials (RCTs) were considered. A minimum length of trial and requirements for a follow-up were not included, and participants in included studies had a diagnosis of dementia of any type and severity. The review considered all trials using fragrance from plants defined as aroma therapy as an intervention with people with dementia. Several outcomes were considered in this review, including cognitive function, quality of life, and relaxation. The titles and abstracts extracted by the searches were screened for their eligibility for potential inclusion in the review, which revealed 2 RCTs of aroma therapy for dementia. Neither of these had published results in a form that we could use. However, individual patient data from one trial were obtained (Ballard 2002) and additional analyses performed. Analysis of co-variance was used for all outcomes, using a random effects model. The additional analyses conducted revealed a statistically significant treatment effect in favour of the aroma therapy intervention on measures of agitation and neuropsychiatric symptoms. Aroma therapy showed benefit for people with dementia in the only trial that contributed data to this review, but there were several methodological difficulties with this study. More well designed large-scale RCTs are needed before conclusions can be drawn on the effectiveness of aroma therapy. Additionally, several issues need to be addressed, such as whether different aroma therapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.

Propentofylline for dementia

Propentofylline is a novel therapeutic agent for dementia that readily crosses the blood-brain barrier and acts by blocking the uptake of adenosine and inhibiting the enzyme phosphodiesterase. In vitro and in vivo its mechanism of action appears to be twofold; it inhibits the production of free radicals and reduces the activation of microglial cells. It therefore interacts with the inflammatory processes that are thought to contribute to dementia, and given its mechanism of action is a possible disease modifying agent rather than a purely symptomatic treatment. To determine the clinical efficacy and safety of propentofylline for people with dementia. The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 5 February 2003. Aventis, the manufacturing pharmaceutical company, was asked for data from unpublished studies but declined to enter into correspondence. Unconfounded double-blind randomized controlled trials of propentofylline compared with a placebo or another treatment group. There were detailed reports of only four of the nine included studies. The efficacy of propentofylline was reviewed for undifferentiated dementia as there were not enough data to attempt a subgroup analysis for the types of dementia. The following statistically significant treatment effects in favour of propentofylline are reported. Cognition at 3, 6 and 12 months including MMSE at 12 months. [MD 1.2, 95%CI 0.12 to 2.28, P=0.03] Severity of dementia at 3, 6 and 12 months including CGI at 12 months [MD -0.21, 95%CI -0.39 to -0.03, P=0.03]. Activities of Daily Living (NAB) at 6 and 12 months [MD -1.20, 95%CI -2.22 to -0.18, P=0.02]. Global Assessment (CGI) at 3 months [MD -0.48, 95% CI -0.75 to -0.21, P=0.0006], but not at later times. Tolerability There were minimal data on adverse effects and drop-outs. There were a statistically significant treatment effects in favour of placebo at 12 months, for the number of dropouts, [OR=1.43, 95%CI 1.04 to 1.90, P=0.03]. There is limited evidence that propentofylline might benefit cognition, global function and activities of daily living of people with Alzheimer's disease and/or vascular dementia. The meta-analyses reported here are far from satisfactory as a summary of the efficacy of propentofylline, considering the unpublished information on another 1200 patients in randomized trials that exists. Unfortunately Aventis has been unwilling to correspond with the authors, significantly limiting the scope of this review.

Acetyl-L-carnitine for dementia.

Dementia is a common mental health problem affecting 5% of those over 65. Various pathological processes are linked to memory impairment in dementia, particularly those affecting the cholinergic neurotransmitter system. Acetyl-l-carnitine (ALC) is derived from carnitine and is described as having several properties which may be beneficial in dementia. This includes activity at cholinergic neurons, membrane stabilization and enhancing mitochondrial function. Work on the effects of ALC has been ongoing since the 1980s yet the efficacy of ALC in cognitive decline remains unclear. Early studies suggested a beneficial effect of ALC on cognition and behaviour in aging subjects. However, later, larger studies have not supported these findings. Some of the difficulties lie in the early and later studies differing widely in methodology and assessment tools used, and are therefore difficult to compare. ALC is not currently in routine clinical use. The objective of this review is to establish whether Acetyl-l-carnitine is clinically effective in the treatment of people with dementia. The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 8 January 2003 using the terms acetyl-l-carnitine, l-carnitine acetyl ester, acetylcarnitine. All double-blind, randomized, trials involving people with dementia in which treatment with ALC was compared with a placebo group Data were extracted by a reviewer (SH) and entered into Revman 4.1 software. Where possible intention-to-treat data were used, but most of the analyses were of completers (people who completed the study). There are 11 included trials, all of which had restricted the participants to people with Alzheimer's disease. All trials assessed the cognitive effects of ALC and in addition six considered severity of dementia, six considered functional ability and six considered clinical global impression. There were statistically significant treatment effects in favour of ALC at 12 and 24 weeks for the numbers showing improvement as determined by Clinical Global Impression, [OR 2.33, 95% CI 1.25 to 4.35, P<0.01] and [OR 3.91, 95% CI 1.32 to 11.54, P=0.01] but not as determined by the CIGIC at 52 weeks. There was no evidence of benefit for ALC in the areas of cognition, severity of dementia, functional ability or Clinical Global Impression as a continuous measure. Various adverse events were reported, but from the meta-analyses there were no statistically significant differences between treated and placebo groups. There is evidence for benefit of ALC on clinical global impression, but there was no evidence using objective assessments in any other area of outcome. Given the large number of comparisons made, the statistically significant result may be due to chance. At present there is no evidence to recommend its routine use in clinical practice. Although the intention of the review was to access ALC for the treatment of all dementias, the included trials had confined themselves to participants with Alzheimer's disease. Individual patient data may add to the findings, as would trials including other types of dementia and other outcomes (e.g. mood and caregiver quality of life). However, the evidence does not suggest that ALC is likely to prove an important therapeutic agent. More work on the pharmacokinetics of ALC in humans is also required.

Randomised, double-blind, placebocontrolled parallel group study of P54FP for the treatment of dogs with osteoarthritis

P54FP is an extract of Indian and Javanese turmeric, Curcuma domestica and Curcuma xanthorrhiza respectively, which contains a mixture of active ingredients including curcuminoids and essential oils. A randomised, double-blind,...

Comparative Haemodynamic Responses to the First Dose of Short- and Long-acting ACE Inhibitors in Patients with Congestive Heart Failure

Angiotensin Converting Enzyme inhibitors (ACEi's) confer significant mortality and morbidity benefits in all functional grades of chronic heart failure (CHF). However, physicians' concerns regarding the possible occurrence of first-dose hypotension appear to be a contributing factor to their under-utilisation in both hospital and primary care settings. We investigated whether long-acting and short-acting ACEi's differ in their haemodynamic responses to the first-dose in patients with CHF.This was a multicentre, randomised, open, two-parallel-group study of captopril 6.25 mg and perindopril 2 mg. 240 patients with CHF, age 68.9 +/- 8.9 years, of whom 66% were male, NYHA II-IV, with average blood pressure baseline values of 132.2 +/- 16.2/78.5 +/- 10.5 mmHg for systolic and diastolic blood pressure, and left ventricular ejection fraction (LVEF) of 31.3 +/- 7.4% received either captopril (n = 124) or perindopril (n = 116). Blood pressure was continuously monitored during the 8 h following drug intake. Minimum levels and maximum decreases in systolic, diastolic and mean arterial pressures were measured, along with the incidence of hypotensive episodes defined as mean blood pressure (MBP) fall > 20 mmHg, whether symptomatic or not. Subgroups of patients distributed according to age, baseline blood pressure (BP) and LVEF were subsequently analysed.Overall, a statistically significant treatment effect in favour of perindopril was observed. First-dose hypotension was observed more frequently following captopril than perindopril administration, with lower MAP minimal levels (78.0 +/- 8.9 vs. 84.5 +/- 10.1 mmHg, p < 0.0001), greater maximum falls (17.6 +/- 8.3 vs. 12.8 +/- 7.3 mmHg, p < 0.0001) and more frequent hypotensive episodes (42% vs. 15%, p < 0.0001). The incidence of at least one symptomatic episode was also significantly higher with captopril (10 patients vs. one patient, p = 0.029). Subgroup analyses according to age (< or = 70 years or > 70 years) or LVEF (< or = 30% or > 30%) reflected the main result.Initiation of treatment with ACE inhibitors is associated with different haemodynamic and clinical tolerances in CHF patients, regardless of their risk for hypotension, with possible clinical implications.

Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic Cochrane review.

Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain. The objective of this review was to determine the efficacy of any form of surface ES in the prevention and/or treatment of pain around the shoulder at any time after stroke. We searched the Cochrane Stroke Review Group trials register and undertook further searches of Medline, Embase and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES. We considered all randomized trials that assessed any surface ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain. Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant change in pain incidence (odds ratio (OR) 0.64; 95% CI 0.19-2.14) or change in pain intensity (standardized mean difference (SMD) 0.13; 95% CI -1.0-1.25) after ES treatment compared with control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (weighted mean difference (WMD) 9.17; 95% CI 1.43-16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI -0.14-0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28-0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder. The evidence from randomized controlled trials so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation. A possible mechanism is through the reduction of glenohumeral subluxation. Further studies are required.

Comparative Haemodynamic Responses to the First Dose of Short- and Long-acting ACE Inhibitors in Patients with Congestive Heart Failure

SummaryBackground: Angiotensin Converting Enzyme inhibitors (ACEi's) confer significant mortality and morbidity benefits in all functional grades of chronic heart failure (CHF). However, physicians' concerns regarding the possible occurrence of first-dose hypotension appear to be a contributing factor to their under-utilisation in both hospital and primary care settings. We investigated whether long-acting and short-acting ACEi's differ in their haemodynamic responses to the first-dose in patients with CHF.Method: This was a multicentre, randomised, open, two-parallel-group study of captopril 6.25 mg and perindopril 2mg. 240 patients with CHF, age 68.9 ± 8.9 years, of whom 66% were male, NYHAII—IV, with average blood pressure baseline values of 132.2 ± 16.2/78.5 ± 10.5mmHg for systolic and diastolic blood pressure, and left ventricular ejection fraction (LVEF) of 31.3 ± 7.4% received either captopril (n = 124) or perindopril (n = 116). Blood pressure was continuously monitored during the 8 h following drug intake. Minimum levels and maximum decreases in systolic, diastolic and mean arterial pressures were measured, along with the incidence of hypotensive episodes defined as mean blood pressure (MBP) fall > 20mmHg, whether symptomatic or not. Subgroups of patients distributed according to age, baseline blood pressure (BP) and LVEF were subsequently analysed.Results: Overall, a statistically significant treatment effect in favour of perindopril was observed. First-dose hypotension was observed more frequently following captopril than perindopril administration, with lower MAP minimal levels (78.0 ± 8.9 vs. 84.5 ± 10.1 mmHg, p < 0.0001), greater maximum falls (17.6 ± 8.3 vs. 12.8 ± 7.3mmHg, p < 0.0001) and more frequent hypotensive episodes (42% vs. 15%, p < 0.0001). The incidence of at least one symptomatic episode was also significantly higher with captopril (10 patients vs. one patient, p = 0.029). Subgroup analyses according to age (< 70 years or > 70 years) or LVEF (< 30% or > 30%) reflected the main result.Conclusion: Initiation of treatment with ACE inhibitors is associated with different haemodynamic and clinical tolerances in CHF patients, regardless of their risk for hypotension, with possible clinical implications.

Electrical stimulation for preventing and treating post-stroke shoulder pain.

Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain. The objective of this review was to determine the efficacy of any form of surface ES in the prevention and / or treatment of pain around the shoulder at any time after stroke. We searched the Cochrane Stroke Review Group trials register and undertook further searches of MEDLINE, EMBASE and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES. We considered all randomised trials that assessed any surface ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain. Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant change in pain incidence (Odds Ratio (OR) 0.64; 95% CI 0.19 to 2.14) or change in pain intensity (Standardised Mean Difference (SMD) 0.13; 95% CI -1.0 to 1.25) after ES treatment compared to control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (Weighted Mean Difference (WMD) 9.17; 95% CI 1.43 to 16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI -0.14 to 0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28 to 0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder. The evidence from randomised controlled trials so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation. A possible mechanism is through the reduction of glenohumeral subluxation. Further studies are required.