SUPPORT Tools for evidence-informed health Policymaking (STP) 8: Deciding how much confidence to place in a systematic review

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.The reliability of systematic reviews of the effects of health interventions is variable. Consequently, policymakers and others need to assess how much confidence can be placed in such evidence. The use of systematic and transparent processes to determine such decisions can help to prevent the introduction of errors and bias in these judgements. In this article, we suggest five questions that can be considered when deciding how much confidence to place in the findings of a systematic review of the effects of an intervention. These are: 1. Did the review explicitly address an appropriate policy or management question? 2. Were appropriate criteria used when considering studies for the review? 3. Was the search for relevant studies detailed and reasonably comprehensive? 4. Were assessments of the studies' relevance to the review topic and of their risk of bias reproducible? 5. Were the results similar from study to study?     

Support to family carers of patients with frontotemporal dementia

Objectives: To examine the provision of support to patients with frontotemporal dementia (FTD) and their family carers compared with patients with early onset Alzheimer's dementia (AD) and their carers, and the carers' satisfaction with the support. Method: Data came from 60 dyads of patients with dementia and their principal family carers, 23 subjects with frontotemporal dementia and their 23 carers, and 37 subjects with early onset Alzheimer's disease and their 37 carers. Results: Patients with a frontotemporal dementia diagnosis were significantly more frequently offered stays in nursing homes (p = 0.04). Carers of patients with frontotemporal dementia were significantly less satisfied with the provision of information about the disease compared with carers of early onset Alzheimer's disease patients (p = 0.05) and were significantly less satisfied with counseling and follow-up advice (p = 0.05). Conclusion: Changes of personality in patients with frontotemporal dementia may be the major reason why they were offered more stays in institutions. These family carers tend to be less satisfied with the provision of support they received from the specialist health service compared to carers of Alzheimer's disease patients, and are in need of more, and other forms of support.     

Sexual function in ICU survivors more than 3 years after major trauma

Objective To study sexual function in trauma patients 3–8 years after discharge from an ICU and to assess determinants of poor sex life. Design and setting A postal questionnaire survey was conducted in 2006 on a cohort of 325 consecutive adult ICU trauma patients admitted to a university hospital during 1998–2003. Patients Of 210 eligible patients 156 (74%) answered the questionnaires. Mean age was 46 years, and 124 were males. Measurements and results Sexual function was assessed by a self-report measure, and patients were asked to describe sexual life both currently and prior to trauma. The International Index of Erectile Function evaluated erectile function in males. At follow-up 50% reported sexual function to be unchanged, 41% impaired, and 9% to be better than preinjury status; 34% reported that the trauma impaired current sex life. Erectile dysfunction was found in 27% of men younger than 40 years and 51% of men 40 years or older. Age, being single, Injury Severity Score, and depression were associated with poor sexual function. Of 17 patients experiencing breakdown of a regular relationship 71% reported the trauma to be a significant contributor. Conclusions At follow-up more than 3 years after injury one-third of our ICU trauma patients reported that the trauma impaired sexual function. Erectile dysfunction was significantly more frequent among men younger than 40 years than found in studies of the normal population. Evaluation of sexual function should be part of long-term outcome assessment after major trauma. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Frequency and characteristics of recurrent major depressed patients with unimpaired executive functions.

Major depression is associated with impairment of cognitive functions, and especially higher-order cognitive processes referred to as executive functions (EF). Whether this is a general finding is unclear. Patients without EF impairment may have different treatment needs than patients with EF impairment, and will probably have a better everyday functioning. Thus, it is important to identify the prevalence and characteristics of depressed patients without EF impairment. Forty-three patients with recurrent major depressive disorder (19-51 years) and 50 healthy controls were included in the study. The subjects were assessed with neuropsychological tests selected to measure central areas of EF, and screened on clinical and demographic variables. Within the depressed group, a total of 56% were defined as EF unimpaired. These patients were characterised by higher intellectual abilities and fewer depression episodes than the subgroup of patients with EF impairment. The subgroups were similar in age at debut of illness, severity of depression, general psychopathology and global level of functioning. In conclusion, about half of patients with recurrent major depression have normal EF. Since cognitive impairment and depressive symptomatology seem to be distinct dimensions, a neuropsychological investigation could help to ensure optimal treatment in patients with recurrent major depression.     

Assessment of myocardial blood volume and water exchange: theoretical considerations and in vivo results.

The measured signal response in contrast-enhanced myocardial perfusion imaging has been shown to be affected by the rate of water exchange between the intravascular and extravascular compartments, the effect being particularly significant when intravascular contrast agents are used. In the present study, the T(1) relaxation rates were measured in eight pigs in blood and myocardium using a Look-Locker sequence after repeated injections of the intravascular contrast agent NC100150. The selection of myocardial region of interest was automated based on a minimum chi-square method. The intra- and extravascular water exchange rates and the myocardial blood volume were calculated from the measured relaxation rates by applying a two-compartment water exchange limited model that accounts for biexponential longitudinal relaxation. The following (mean +/- SD) values were obtained for the exchange frequency (f), the extravascular residence time (tau(e)), the intravascular residence time (tau(i)) and blood volume (BV), respectively: f = 1.39 +/- 0.52 s(-1), tau(e) = 708 +/- 264 ms, tau(i) = 107 +/- 63 ms, and BV = 11.2 +/- 2.1 mL/100 g. The mean value of f was found to be about 15% higher if biexponential relaxation was not accounted for, supporting the hypothesis that significant biexponential relaxation in tissues with large blood volume can lead to an overestimation of water exchange rates unless corrected for.     

Experimental application of thermosensitive paramagnetic liposomes for monitoring magnetic resonance imaging guided thermal ablation.

The use of a liposomal paramagnetic agent with a T(1)-relaxivity that increases markedly at temperatures above the phase transition temperature (T(m)) of the liposomal membrane was evaluated during magnetic resonance imaging (MRI) guided hyperthermia ablation. A neodymium-yttrium aluminum garnet (Nd-YAG) laser unit and a radiofrequency ablation system were used for tissue ablation in eight rabbit livers in vivo. One ablation was made in each animal prior to administration of the liposomal agent. Liposomes with a T(m) of 57 degrees C containing gadodiamide (GdDTPA-BMA) were injected iv, and two additional ablations were performed. T(1)-weighted scans were performed in heated tissue, after tissue temperature had normalized, and 15-20 min after normalization of tissue temperature. Increase in signal intensity (DeltaSI) for ablations prior to injection of the agent was 13.0% (SD = 5.7) for the laser group and 9.1% (SD = 7.9) for the radiofrequency group. Signal intensity after administration of the agent unrelated to heating was not statistically significant (DeltaSI = 1.4%, P = 0.35). For ablations made after injection of the agent, a significant increase was found in the laser (DeltaSI = 34.5%, SD = 11.9) and radiofrequency group (DeltaSI = 21.6%, SD = 22.7). The persistent signal enhancement found in areas exposed to a temperature above the threshold temperature above T(m) allows thermal monitoring of MRI guided thermal ablation.     

Attentional and executive dysfunctions in schizophrenia and depression: evidence from dichotic listening performance.

BACKGROUND: We compared performance on a dichotic listening (DL) task between schizophrenic, depressed, and healthy control subjects. A variant of the traditional DL paradigm was used in which the subjects were required to focus attention either on the left (forced-left condition) or right (forced-right condition) ear stimulus. METHODS: The subjects were 51 patients with a DSM-IV diagnosis of schizophrenia, 49 patients with recurrent unipolar major depression, and 49 healthy control subjects. They were tested with a consonant-vowel syllables dichotic listening task under three attentional instructions. RESULTS: There was a significant overall right ear advantage during the nonforced condition, which increased dramatically during the forced-right condition and was eliminated during the forced-left condition. The depressed patients showed no signs of impairments compared with the healthy control group. Thus, they showed a right ear advantage during the nonforced and forced-right conditions, which was shifted to a left ear advantage during the forced left condition. The schizophrenic patients, however, were impaired on the forced-left condition compared with the healthy control and depressed subjects. CONCLUSIONS: The results are discussed in terms of separating attentional and inhibitory executive impairments in schizophrenia and depression, taking into consideration illness duration and information-processing demands.     

Multiple organ failure after trauma affects even long-term survival and functional status

Background  

The aim of this study was to assess the incidence of organ failure in trauma patients treated in an intensive care unit (ICU), and to study the relationship between organ failure and long-term survival and functional status.