Usual Medical Treatment Research Articles

Effect of Urticaria Spray on the Pain Severity in Chronic Low Back Pain Patients Referring to an Orthopedic Clinic

Introduction: Regarding serious impact of chronic back pain in quality of life of people, patients looking for treatment to relieve back pain. The anti- inflammatory properties of nettle plant (Urtica dioica) as spray in reducing severity of low back pain was investigated. Materials and Methods: This study as a registered controlled clinical trial (IRCT: 20171217037930N1) recruited 40 patients with chronic back pain who referred to Orthopedic clinic of Sabzevar Shahid Beheshti Hospital, Sabzevar, Iran by available sampling method. Patients were divided randomly into two groups; group A: treatment with utricaria spray and usual medical treatment (20 persons), group B: patients under just usual medical treatment (20 persons). Pain measurement tool carried out under the visual analog scale (VAS) after intervention into both groups, and data were analyzed by SPSS software. Results: Both studied groups had the similar VAS before the study (P=0.15). Analysis of VAS showed that the average pain severity after intervention was decreased significantly into both studied groups (P=0.01). However these decrements in VAS were not statistically significant between two studied groups (P=0.06). Multiple linear regression analysis determined that utricaria spray could be decreased pain severity to averagely till 0.79%. Conclusion: We concluded that adding utricaria spray to usual treatment has no effect into decreasing chronic low back pain.

Progestogen-releasing intrauterine systems for heavy menstrual bleeding.

Progestogen-releasing intrauterine systems for heavy menstrual bleeding.

External trigeminal nerve stimulation for drug resistant epilepsy: A randomized controlled trial

BackgroundExternal trigeminal nerve stimulation (ETNS) is an emergent, non-invasive neurostimulation therapy delivered bilaterally with adhesive skin electrodes. In previous studies, ETNS was associated to a decrease in seizure frequency in patients with focal drug-resistant epilepsy (DRE). ObjectiveTo determine the long-term efficacy and tolerability of ETNS in patients with focal DRE. Moreover, to explore whether its efficacy depends on the epileptogenic zone (frontal or temporal), and its impact on mood, cognitive function, quality of life, and trigeminal nerve excitability. MethodsForty consecutive patients with frontal or temporal DRE, unsuitable for surgery, were randomized to ETNS or usual medical treatment. Participants were evaluated at 3, 6 and 12 months for efficacy, side effects, mood scales, neuropsychological tests and trigeminal nerve excitability. ResultsSubjects had a median of 15 seizures per month and had tried a median of 12.5 antiepileptic drugs. At 12 months, percentage of responders was 50% in ETNS group and 0% in control group. Seizure frequency in ETNS group decreased by −43.5% from baseline. Temporal epilepsy subgroup responded better than frontal epilepsy subgroup (55.56% vs. 45.45%, respectively). Median stimulation intensity was 6.2 mA. ETNS improved quality of life, but not anxiety or depression. Long-term ETNS affected neither neuropsychological function, nor trigeminal nerve excitability. No relevant adverse events were observed. ConclusionsETNS is an effective and well-tolerated therapy for focal DRE. Patients with temporal epilepsy showed a better response than those with frontal epilepsy. Future studies with larger populations may define its role compared to other neurostimulation techniques. Classification of evidenceThis study provides Class II evidence that ETNS reduces seizure frequency in patients with focal DRE.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study

BackgroundAcute dyspnoea is common among ambulance patients, but little is known of the patients’ experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.MethodsWe performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.ResultsWe included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6–10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6–9) to 4 (2–5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.ConclusionsWe found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients’ experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Diverse Mechanisms Lead to Common Dysfunction of Striatal Cholinergic Interneurons in Distinct Genetic Mouse Models of Dystonia.

Clinical and experimental data indicate striatal cholinergic dysfunction in dystonia, a movement disorder typically resulting in twisted postures via abnormal muscle contraction. Three forms of isolated human dystonia result from mutations in the TOR1A (DYT1), THAP1 (DYT6), and GNAL (DYT25) genes. Experimental models carrying these mutations facilitate identification of possible shared cellular mechanisms. Recently, we reported elevated extracellular striatal acetylcholine by in vivo microdialysis and paradoxical excitation of cholinergic interneurons (ChIs) by dopamine D2 receptor (D2R) agonism using ex vivo slice electrophysiology in Dyt1ΔGAG/+ mice. The paradoxical excitation was caused by overactive muscarinic receptors (mAChRs), leading to a switch in D2R coupling from canonical Gi/o to noncanonical β-arrestin signaling. We sought to determine whether these mechanisms in Dyt1ΔGAG/+ mice are shared with Thap1C54Y/+ knock-in and Gnal+/- knock-out dystonia models and to determine the impact of sex. We found Thap1C54Y/+ mice of both sexes have elevated extracellular striatal acetylcholine and D2R-induced paradoxical ChI excitation, which was reversed by mAChR inhibition. Elevated extracellular acetylcholine was absent in male and female Gnal+/- mice, but the paradoxical D2R-mediated ChI excitation was retained and only reversed by inhibition of adenosine A2ARs. The Gi/o-preferring D2R agonist failed to increase ChI excitability, suggesting a possible switch in coupling of D2Rs to β-arrestin, as seen previously in a DYT1 model. These data show that, whereas elevated extracellular acetylcholine levels are not always detected across these genetic models of human dystonia, the D2R-mediated paradoxical excitation of ChIs is shared and is caused by altered function of distinct G-protein-coupled receptors.SIGNIFICANCE STATEMENT Dystonia is a common and often disabling movement disorder. The usual medical treatment of dystonia is pharmacotherapy with nonselective antagonists of muscarinic acetylcholine receptors, which have many undesirable side effects. Development of new therapeutics is a top priority for dystonia research. The current findings, considered in context with our previous investigations, establish a role for cholinergic dysfunction across three mouse models of human genetic dystonia: DYT1, DYT6, and DYT25. The commonality of cholinergic dysfunction in these models arising from diverse molecular etiologies points the way to new approaches for cholinergic modulation that may be broadly applicable in dystonia.

Motor cortex stimulation for refractory demyelinating disease-associated trigeminal neuralgia

Patients with demyelinating diseases (DDs) such as multiple sclerosis have a 20-fold higher risk of developing trigeminal neuralgia (TN). DD-related TN is more frequently refractory to the usual medical and surgical treatment. We report the case of a 57-year-old man presenting to our neurology outpatient clinic with a 12-year history of medical and surgical refractory TN associated with demyelinating lesions on magnetic resonance imaging. After a new failure of pharmacological treatment with oxcarbazepine, pregabalin, baclofen, and duloxetine, motor cortex stimulation (MCS) was performed, and the patient remained mostly pain-free, without any pharmacological treatment during the 3.5 years of follow-up. MCS may be a useful approach for DD-related refractory TN, and further studies can clarify its role in TN management.

Analysis of the efficacy of an internet-based self-administered intervention (“Living Better”) to promote healthy habits in a population with obesity and hypertension: An exploratory randomized controlled trial

IntroductionChanges in unhealthy lifestyles are key elements in the prevention and treatment of obesity and hypertension. Internet-based programs offer great potential for the implementation of evidence-based interventions focused on promoting healthy habits. We evaluate the efficacy of an Internet-based self-administered program (“Living Better”) that addresses people diagnosed as being overweight or having type I obesity and hypertension. MethodsThe sample was composed of a total of 106 participants (age Mean = 53; 59 males) from a public hospital in Spain, diagnosed as being overweight or having type I obesity and hypertension and randomized into two groups—the intervention group (IG; Internet-based intervention) and the control group (CG; usual medical treatment). The intervention used cognitive-behavioral strategies and psychoeducation to promote healthy habits. Anthropometric data (i.e., Body Mass Index –BMI-, waist circumference, and hip circumference) and lifestyle/psychological data (i.e., quality of life, physical activity, eating styles, motivation, mood, and self-efficacy) were assessed before and after the intervention, and at 6 and 12-month follow-ups. ResultsSignificant differences were observed between the IG and the CG in anthropometrical variables after intervention (i.e., BMI and waist circumference), external eating style, and anxiety and stress scores (p < 0.05). Follow-up data showed that changes were maintained in BMI, waist and hip circumference, and external eating in the IG. After receiving the Internet-based treatment, the CG also improved its clinical condition. DiscussionThis study demonstrates that the Internet is a viable alternative for the delivery and dissemination of interventions focused on promoting healthy habits, and a totally self-administered intervention can produce long-term positive results.

Promoting nighttime sleep in the intensive care unit: Alternative strategies in nursing

AimTo identify if complementary interventions impacted on conscious intensive care patients’ perception of stress factors and quality of sleep. Research methodologyA non-controlled clinical study was undertaken on conscious patients in an intensive care unit in central Italy.Patients perception of stress factors and quality of sleep during the first night with usual medical and nursing treatments was measured using two questionnaires: the Stress Factors in Intensive Care Unit Questionnaire and the Modified Richards-Campbell Sleep Questionnaire.During the second night two specific treatments were administered: (1) receptive musical sounds and (2) a massage using sweet lavender/lemon-scented almond oil.The same variables were measured on the third day using the same questionnaires. ResultsThe data of 74 patients were analysed. The patients’ main concerns were “hearing unusual noises” (n = 46, 62.2%), “having people continuously working around the bed” (n = 53, 71.6%), “being worried” (n = 60, 81.1%) and “being unable to sleep” (n = 47, 63.5%). Fifty-three patients (71.6%) reported waking up in the middle of the night and 21 (28.3%) of them were unable to fall asleep again. Receptive musical sounds and massage using aromatherapy improved the quality of patients’ sleep (t = 2.01, p = 0.047). ConclusionComplementary interventions may reduce patients’ perception of stress and improve their sleep. Further research is now needed.

Methylation of the glucocorticoid receptor gene associated with depression in patients with acute coronary syndrome

ObjectiveThe present study investigated the longitudinal effects of NR3C1 1 F exon methylation on the risk of depression following ACS and treatment outcomes. MethodsIn total, 969 patients admitted for recent ACS were recruited within 2 weeks of ACS; 711 of these patients were followed up at 1 year. Depressive disorder was diagnosed according to DSM-IV criteria and included prevalent depressive disorder at baseline and incident or persistent depressive disorder at follow-up based on depression status at the two examinations. Of the 378 baseline participants who were diagnosed with depression, 255 participated in a randomized double-blind placebo-controlled trial of escitalopram, while the remaining 123 were managed with the usual medical treatment for ACS.NR3C1 1 F exon methylation was measured using peripheral blood samples, and various demographic and clinical characteristics were assessed as covariates. ResultsHigher NR3C1 1 F exon methylation levels were independently associated with prevalent depressive disorder at baseline but not with incident or persistent depressive disorder at follow-up based on logistic regression analyses adjusted for covariates. The effects of escitalopram on the remission of depressive symptoms was not influenced by NR3C1 1 F exon methylation status in ACS patients, but a placebo effect on the remission of depressive symptoms was observed, particularly in patients with lower methylation levels. ConclusionsACS patients with higher NR3C1 1 F exon methylation levels were at higher risk of developing depressive disorder within 2 weeks of ACS. Additionally, adequate antidepressant treatment may be effective for the remission of depressive symptoms regardless of NR3C1 1 F exon methylation status.

Psychiatric Symptoms in Refractory Epilepsy During the First Year After Surgery

Psychiatric morbidity in drug-resistant epilepsy is frequent. Surgery is the best therapeutic alternative for treating seizures, but the current evidence concerning the effects of surgery on psychiatric disorders (PDs) is inconclusive. We aim to clarify surgery's role in long-term PDs. Using a prospective controlled study, we analyzed the psychopathologic outcomes of patients with drug-resistant epilepsy, comparing those who underwent surgery to those who did not due to not being suitable. Surgical candidates were paired (n = 84) with the immediately following nonsurgical candidates (n = 68). Both groups continued their usual medical treatment. We studied psychiatric changes for each group and analyzed de novo and remission cases. The assessments were made during the presurgical evaluation, and at 6 months (6-M) and 12 months (12-M) after surgery. Finally, we determined associated factors for postsurgical PDs. At 12 months, using the Hospital Anxiety and Depression Scale (HADS), anxiety improved in both groups (p = 0.000), while depression improved only in the surgical group (p = 0.016). Moreover, all symptom dimensions on the Symptom Checklist-90-R (SCL-90), as well as severity, distress, and total symptoms, decreased only in the surgical group. These ameliorations reached not only statistical significance but also clinical significance for depression (HADS) (p = 0.014) and the interictal dysphoric disorder (p = 0.013). The main predictors for PDs after surgery were as follows: the presurgical and 6-month psychiatric symptoms, the absence of surgery, seizure outcomes, and some antiepileptic and psychiatric drugs. This study provides evidence that surgery for epilepsy could have a role in improving some symptoms of psychiatric disorders 12-M after the surgery.

The effectiveness comparison of same balneotherapy applications with different frequency within different time periods in patients with fibromyalgia; a randomized controlled single blind study

Aim: To observe the short and middle term effects of intermittent and consecutive (traditional) regimens of same balneotherapy applications in patients with fibromyalgia syndrome. Material and Method: Fifty female patients who were diagnosed as fibromyalgia syndrome according to the American College of Rheumatology 2010 criteria were randomly assigned to either consecutive (group 1) or intermittent treatment (group 2) groups. After randomization 5 patients from each group dropped out from the study with different excuses. Both groups received 20 minutes of full body immersion in tap water (at 38°C) and 30 minutes of mud pack treatment (at 45°C) on back region. Treatments in group1 (n=25) were delivered 5 weekdays for 2 consecutive weeks, and for group 2 (n=25) 2 times weekly for 5 consecutive weeks (totally 10 sessions for both groups) in Hydroclimatology Therapy Unit. All patients continued to use their usual medical treatment. An investigator who was blinded to the interventions assessed all the patients before and after the treatment, at the first and the third month of follow-up. Outcome measures were pain, patient’s and physician’s global assessments on VAS, tender point count, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Index (BDI) and the Health Assessment Questionnaire (HAQ). Results: There was a statistically significant improvement in both groups in terms of pain (VAS) and tender point count at the end of the treatment that lasted up to the 3rd month. Results were found to be the same for physician’s global assessments (VAS) except for after treatment evaluation. While there was a significant improvement in patient’s global assessment (VAS) and BDI at the 3rd month follow-up for group 1, group 2 was observed to have significant improvements during all the assessments for patient’s global assessment (VAS) and at 1st and 3rd month controls for FIQ. In between-group comparisons, group 2 was found to be superior for fatigue (at 1st month) and pain subscales (at 3rd month) of FIQ. Conclusion: The consecutive or intermittent delivery of ambulatory balneotherapy programs, consisting of full body immersion in heated tap water and mud pack treatment on back region, both are effective in the treatment of fibromyalgia. For some parameters evaluating pain and fatigue intermittent treatment seems to be superior.

Muscle stretching exercises and resistance training in fibromyalgia: which is better? A three-arm randomized controlled trial.

Exercise therapy is an effective component of fibromyalgia (FM) treatment. However, it is important to know the effects and specificities of the different types of exercise: muscle stretching and resistance training. To verify and compare the effectiveness of muscle stretching exercise and resistance training for symptoms and quality of life in FM patients. Randomized controlled trial. Physical therapy service, FM outpatient clinic. Forty-four women with FM (79 screened). Patients were randomly allocated into a stretching group (N.=14), resistance group (N.=16), and control group (N.=14). Pain was assessed using the visual analog scale, pain threshold using a Fischer dolorimeter, FM symptoms using the Fibromyalgia Impact Questionnaire (FIQ), and quality of life using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The three intervention groups continued with usual medical treatment. In addition, the stretching and resistance groups performed two different exercise programs twice a week for 12 weeks. After treatment, the stretching group showed the highest SF-36 physical functioning score (P=0.01) and the lowest bodily pain score (P=0.01). The resistance group had the lowest FIQ depression score (P=0.02). The control group had the highest score for FIQ morning tiredness and stiffness, and the lowest score for SF-36 vitality. In clinical analyses, the stretching group had significant improvement in quality of life for all SF-36 domains, and the resistance group had significant improvement in FM symptoms and in quality of life for SF-36 domains of physical functioning, vitality, social function, emotional role, and mental health. Muscle stretching exercise was the most effective modality in improving quality of life, especially with regard to physical functioning and pain, and resistance training was the most effective modality in reducing depression. The trial included a control group and two intervention groups, both of which received exercise programs created specifically for patients with FM. In clinical practice, we suggest including both modalities in an exercise therapy program for FM.

Investigating the Effect of Nurse-Centered Strategies on Functional Chronic Constipation of Children aged 3-14 years Referring to Imam Reza Clinic of Shiraz University of Medical Sciences in 2014

Background: Functional constipation is among the most common problems of childhood. Children’s life quality is affected by constipation. In addition, constipation can bring about undesirable physical and psychic consequences. However, follow-up programs can solve the problem and assure the patient about continuing treatment. Objectives: This study aimed to investigate the impact of nurse-based approaches on functional chronic constipation in children. Methods: This is a clinical trial study conducted from August to December 2013 in Imam Reza clinic. The sample size was 95 children who were randomly assigned to two groups of experimental (47 persons) and control (48 persons). The mean age in the experimental and control groups was 6.25 ± 2.71 and 6.21 ± 2.68 years, respectively. The experimental group received a combination of nurse-centered and education program as well as conventional medical treatment while the control group received only the usual medical treatment. The data were collected using a data collecting form and bowel diary. The recovery percentage was assessed based on Rome 3 criteria in three periods of 1, 2, and 3 months after the intervention compared to before the intervention. The collected data were analyzed by SPSS version 16 software using chi square and Mc Nemar tests. Results: Before the intervention, the similarity of people in the study groups that is necessary for clinical trials was observed. In all variables such as constipation status, sex, weight, duration of constipation, previous therapy, and family history of constipation, there was no statistically significant difference between the two groups (P value > 0.05). The results showed improvements in both the groups. The percentage of improvement assessed by chi square test in the intervention group was 70.2%. This percentage increased to 83% about 2 and 3 months after the intervention; in comparison with the control group, the improvement was higher by 14 and 10%, respectively (P value > 0.05). Conclusions: Nurse-based clinics should be established at gastroenterology clinics to minimize the frustration of parents and children in remission and treatment discontinuation through routine follow-up of long-term treatment (either by phone or in person) that may lead a greater number of patients to achieve remission after treatment.

Multidisciplinary Team Treatment Approaches to Chronic Daily Headaches

In this review, we focus on nonmedication treatment approaches to chronic daily headaches and chronic migraine. We review the current scientific data on studies using multimodal treatments, especially physical therapy and occupational therapy, and provide recommendations on the formation of interdisciplinary headache teams. Chronic daily headache, which includes chronic migraine, is a particularly challenging clinical entity which often involves multiple headache types and comorbidities. A team approach in treating these patients may be particularly useful. We review all current studies performed with at least one or more other modality in addition to usual medical treatment, with a focus on physical and occupational therapy. Emphasis on physical and occupational therapy with an explanation of their methods and role in multidisciplinary treatment is a pivotal part of this review. We also suggest approaches to setting up a multimodality clinic for the busy headache clinician. Setting up a collaborative, multidisciplinary team of specialists in headache practices with the goal of modifying physical, environmental, and psychological triggers for chronic daily headaches may facilitate treatment of these refractory patients.

Peripheral nerve block with a high concentration of tetracaine dissolved in bupivacaine for intractable post-herpetic itch: a case report.

BackgroundPost-herpetic itch (PHI) is a neuropathic itch syndrome following herpes zoster. It has been reported that PHI is occasionally sufficiently severe to compromise patients’ quality of life and frequently refractory to treatment. Here, we present a case of severe chronic PHI successfully treated with supraorbital nerve block using a high concentration of tetracaine dissolved in bupivacaine.Case presentationAn 82-year-old man presented with severe chronic itching in the ophthalmic branch of the left trigeminal nerve dermatome, following acute herpes zoster. The patient’s itching was unresponsive to usual medical treatments for PHI including antiepileptic drugs, topical capsaicin cream, and supraorbital nerve radiofrequency thermo-coagulation. Topical lidocaine cream could relieve the itching, but could not provide long-term relief of itching and thus failed to achieve a satisfactory result. After these conventional treatments, left supraorbital nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was conducted. Afterwards, the patient experienced long-lasting resolution of the itching with improvement of sleep disturbance. A transient, mild edema of the eyelids occurred, but there were no other complications.ConclusionsPeripheral nerve block using 4% tetracaine dissolved with 0.5% bupivacaine was beneficial in relieving PHI in the ophthalmic division of the trigeminal nerve.

The Effectiveness of Levonorgestrel-Releasing Intrauterine System in the Treatment of Heavy Menstrual Bleeding.

Levonorgestrel-releasing intrauterine system (LNG-IUS) has been shown to be an effective treatment for patients with abnormal uterine bleeding (AUB) in many Western studies. The purpose of study was to examine the effectiveness of LNG-IUS in the treatment of Indian women with AUB. We conducted a retrospective observational study of 70 women diagnosed with AUB and treated with LNG-IUS insertion between February 2010 and 2014 at the Department of Gynecology of Sree Narayana Institute of Medical Sciences. Baseline endometrial biopsies were done before insertion of LNG-IUS, and outpatient follow-up with symptom diary was undertaken at 3-month intervals after insertion of LNG-IUS. Primary outcome in the two treatment groups was significantly greater among women assigned to levonorgestrel-IUS than among those assigned to usual treatment (mean difference in scores over the course of 1year 13.4 points; 95% confidence interval [CI] 9.9-16.9; P<0.001). All six domains of the MMAS favored the levonorgestrel-IUS at every time point (P<0.001) with the use of a test for trend. In conclusion, our study showed that both the levonorgestrel-IUS and usual medical treatments reduced the adverse effect of menorrhagia on women's lives over the course of 2years, but the levonorgestrel-IUS was the more effective first choice, as assessed by the impact of bleeding on the women's quality of life.

Bénéfices de l’Activité Physique Adaptée couplée à des Interventions Psychologiques ciblées pour les personnes souffrant de Sclérose en Plaques (SEP)

As part of a collaboration between the Centre Sport et Santé of The University of Lausanne and the sports psychologist Mattia Piffaretti, a physical activity program has been adapted for 29 patients suffering from multiple sclerosis. The 29 patients were divided into three research groups. The first group EX (n=5, age=50.6±9.8) followed a bi-weekly physical activity intervention program for a total of 12 weeks in addition to their usual medical treatment. The second group MOT (n=8, age=46.8±8.7) followed a program combining a bi-weekly physical activity intervention (the same as group EX) and bi-monthly exercise psychology sessions for 12 weeks, in addition to their usual medical treatment. The third group Control (n=16, age=47.0±5.4) followed their usual medical treatment. We received 13 patients of the study in the Centre Sport et Santé of The University of Lausanne to give them a specific and adapted physical activity program. This program was divided into shifts “work” and “collective work”. The main objectives of this training were the work of balance (postural control), the work of coordination, building muscle and finally, stretching and joints mobilization. Group work gave the participants a different vision of team sports and allowed them to strengthen relational ties between the group. The global objective of the study, conducted by Mr. Piffaretti, was to determine how much of group physical activity programs, combined or not with targeted psychological interventions inspired by sports psychology, can improve the well-being of patients with Multiple Sclerosis and who have the ability to walk independently.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial.

Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®, Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. Women who presented in primary care. A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. Current Controlled Trials ISRCTN86566246. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Hypnosis Treatment of Gastrointestinal Disorders: A Comprehensive Review of the Empirical Evidence

Hypnotherapy has been investigated for 30 years as a treatment for gastrointestinal (GI) disorders. There are presently 35 studies in the published empirical literature, including 17 randomized controlled trials (RCTs) that have assessed clinical outcomes of such treatment. This body of research is reviewed comprehensively in this article. Twenty-four of the studies have tested hypnotherapy for adult irritable bowel syndrome (IBS) and 5 have focused on IBS or abdominal pain in children. All IBS hypnotherapy studies have reported significant improvement in gastrointestinal symptoms, and 7 out of 10 RCTs in adults and all 3 RCTs in pediatric patient samples found superior outcomes for hypnosis compared to control groups. Collectively this body of research shows unequivocally that for both adults and children with IBS, hypnosis treatment is highly efficacious in reducing bowel symptoms and can offer lasting and substantial symptom relief for a large proportion of patients who do not respond adequately to usual medical treatment approaches. For other GI disorders the evidence is more limited, but preliminary indications of therapeutic potential can be seen in the single randomized controlled trials published to date on hypnotherapy for functional dyspepsia, functional chest pain, and ulcerative colitis. Further controlled hypnotherapy trials in those three disorders should be a high priority. The mechanisms underlying the impact of hypnosis on GI problems are still unclear, but findings from a number of studies suggest that they involve both modulation of gut functioning and changes in the brain’s handling of sensory signals from the GI tract.

Diurnal and day-to-day variation of isometric muscle strength in myasthenia gravis.

In patients with myasthenia gravis (MG), muscle strength is expected to decrease gradually during the day due to physical activities. Isometric muscle strength at the shoulder, knee, and ankle was determined in 10 MG patients (MGFA class II-IV) who were receiving usual medical treatment and in 10 control subjects. To determine diurnal and day-to-day variation, muscle strength was measured 4 times during day 1 and once at day 2. Knee extension strength decreased during the day in both patients and controls. Neither diurnal nor day-to-day variation of muscle strength was higher in patients compared with controls. Patients with mild to moderate MG did not have increased variation of isometric muscle strength during the day or from day-to-day compared with controls. This suggests that isometric muscle performance can be determined with high reproducibility in similar groups of MG patients without regard to time of day.