Applied Health Sciences (Department)
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Item Systematic review of the safety and efficacy of foam sclerotherapy for venous disease of the lower limbs(2007-08) Jia, X.; Mowatt, Graham; Burr, Jennifer Margaret; Cassar, Kevin; Cook, Jonathan Alistair; Fraser, Cynthia Mary; University of Aberdeen.Other Applied Health SciencesItem Screening tests for detecting open angle glaucoma : systematic review and meta-analysis(The Association for Research in Vision and Ophthalmology, Inc., 2008-07-09) Mowatt, Graham; Burr, Jennifer Margaret; Cook, Jonathan Alistair; Siddiqui, M. A. Rehman; Ramsay, Craig R; Fraser, Cynthia Mary; Azuara-Blanco, Augusto; Deeks, Jonathan JPURPOSE. To assess the comparative accuracy of potential screening tests for open angle glaucoma (OAG). METHODS. Medline, Embase, Biosis (to November 2005), Science Citation Index (to December 2005), and The Cochrane Library (Issue 4, 2005) were searched. Studies assessing candidate screening tests for detecting OAG in persons older than 40 years that reported true and false positives and negatives were included. Meta-analysis was undertaken using the hierarchical summary receiver operating characteristic model. RESULTS. Forty studies enrolling over 48,000 people reported nine tests. Most tests were reported by only a few studies. Frequency-doubling technology (FDT; C-20-1) was significantly more sensitive than ophthalmoscopy (30, 95% credible interval [CrI] 0–62) and Goldmann applanation tonometry (GAT; 45, 95% CrI 17–68), whereas threshold standard automated perimetry (SAP) and Heidelberg Retinal Tomograph (HRT II) were both more sensitive than GAT (41, 95% CrI 14–64 and 39, 95% CrI 3–64, respectively). GAT was more specific than both FDT C-20-5 (19, 95% CrI 0-53) and threshold SAP (14, 95% CrI 1-37). Judging performance by diagnostic odds ratio, FDT, oculokinetic perimetry, and HRT II are promising tests. Ophthalmoscopy, SAP, retinal photography, and GAT had relatively poor performance as single tests. These findings are based on heterogeneous data of limited quality and as such are associated with considerable uncertainty. CONCLUSIONS. No test or group of tests was clearly superior for glaucoma screening. Further research is needed to evaluate the comparative accuracy of the most promising tests.Item Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis.(Elsevier Science, 2008) Jia, Xueli; Glazener, Cathryn Margaret Anne; Mowatt, Graham; MacLennan, Graeme Stewart; Fraser, Cynthia Mary; Bain, Christine; Burr, Jennifer MargaretBackground The efficacy and safety of mesh/graft in surgery for anterior or posterior pelvic organ prolapse is uncertain. Objectives To systematically review the efficacy and safety of mesh/graft for anterior or posterior vaginal wall prolapse surgery. Search strategy Electronic databases and conference proceedings were searched, experts and manufacturers contacted and reference lists of retrieved papers scanned. Selection criteria Randomised controlled trials (RCTs), non-randomised comparative studies, registries, case series involving at least 50 women, and RCTs published as conference abstracts from 2005 onwards. Data collection and analysis One reviewer screened titles/abstracts, undertook data extraction, and assessed study quality. Data analysis was conducted for three subgroups: anterior, posterior, and anterior and/or posterior repair (not reported separately). Results Forty-nine studies involving 4569 women treated with mesh/graft were included. Study quality was generally high. Median follow up was 13 months (range 1 to 51). In anterior repair, there was short-term evidence that mesh/graft (any type) significantly reduced objective prolapse recurrence rates compared with no mesh/graft (relative risk 0.48, 95% CI 0.32-0.72). Non-absorbable synthetic mesh had a significantly lower objective prolapse recurrence rate (8.8%, 48/548) than absorbable synthetic mesh (23.1%, 63/273) and biological graft (17.9%, 186/1041), but a higher erosion rate (10.2%, 68/666) than synthetic mesh (0.7%, 1/147) and biological graft (6.0%, 35/581). There was insufficient information to compare any of the other outcomes regardless of prolapse type. Conclusion Evidence for most outcomes was too sparse to provide meaningful conclusions. Rigorous long-term RCTs are required to determine the comparative efficacy of using mesh/graft.Item Clinical and cost-effectiveness of internal limiting membrane peeling for patients with idiopathic full thickness macular hole. Protocol for a Randomised Controlled Trial : FILMS (Full-thickness macular hole and Internal Limiting Membrane peeling Study)(BMC, 2008-11-03) Lois, Noemi; Burr, Jennifer Margaret; Norrie, John David; Vale, Luke David; Cook, Jonathan Alistair; McDonald, Alison Mary; FILMS Group; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health SciencesBackground: A full-thickness macular hole (FTMH) is a common retinal condition associated with impaired vision. Randomised controlled trials (RCTs) have demonstrated that surgery, by means of pars plana vitrectomy and post-operative intraocular tamponade with gas, is effective for stage 2, 3 and 4 FTMH. Internal limiting membrane (ILM) peeling has been introduced as an additional surgical manoeuvre to increase the success of the surgery; i.e. increase rates of hole closure and visual improvement. However, little robust evidence exists supporting the superiority of ILM peeling compared with no-peeling techniques. The purpose of FILMS (Fullthickness macular hole and Internal Limiting Membrane peeling Study) is to determine whether ILM peeling improves the visual function, the anatomical closure of FTMH, and the quality of life of patients affected by this disorder, and the cost-effectiveness of the surgery. Methods/Design: Patients with stage 2–3 idiopathic FTMH of less or equal than 18 months duration (based on symptoms reported by the participant) and with a visual acuity ≤ 20/40 in the study eye will be enrolled in this FILMS from eight sites across the UK and Ireland. Participants will be randomised to receive combined cataract surgery (phacoemulsification and intraocular lens implantation) and pars plana vitrectomy with postoperative intraocular tamponade with gas, with or without ILM peeling. The primary outcome is distance visual acuity at 6 months. Secondary outcomes include distance visual acuity at 3 and 24 months, near visual acuity at 3, 6, and 24 months, contrast sensitivity at 6 months, reading speed at 6 months, anatomical closure of the macular hole at each time point (1, 3, 6, and 24 months), health related quality of life (HRQOL) at six months, costs to the health service and the participant, incremental costs per quality adjusted life year (QALY) and adverse events. Discussion: FILMS will provide high quality evidence on the role of ILM peeling in FTMH surgery. Trial registration: This trial is registered with Current Controlled Trials ISRCTN number 33175422 and Clinical Trials.gov identifier NCT00286507.Item The Accuracy of Accredited Glaucoma Optometrists in the Diagnosis and Treatment Recommendation for Glaucoma(BMJ, 2007-12) Azuara-Blanco, Augusto; Burr, Jennifer Margaret; Thomas, Ruth Elizabeth; MacLennan, Graeme Stewart; McPherson, StephenBackground/aims: To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of, and decision to treat glaucoma with that of routine hospital eye care against a reference standard of expert opinion, i.e. consultant ophthalmologist with a special interest in glaucoma. Methods: A directly comparative, masked, performance study was performed in Grampian, Scotland. 165 people were invited to participate and, of those, 100 (61%) were examined. People suspected of having glaucoma underwent a full ophthalmic assessment both in a newly established, community optometry led, glaucoma management scheme and in a consultant led hospital eye service within a month. Results: The agreement between the AGO and the consultant ophthalmologist in the diagnosis of glaucoma was substantial (89%, kappa = 0.703, SE=0.083). The agreement regarding the need for treatment was also substantial (88%, kappa = 0.716, SE =0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation were moderate (83%, kappa = 0.541, SE = 0.098, SE = 0.98; and 81%, kappa = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 [95% CI 0.85 to 0.97]) but lower for sensitivity at 0.76 (95% CI 0.57 to 0.89). The performance was similar when accuracy was assessed for treatment recommendation (sensitivity, 0.73[95% CI 0.57 to 0.85]; specificity 0.96[95% CI 0.88 to 0.99]). The differences in sensitivity and specificity between AGO and junior ophthalmologist was not statistically significant.Conclusions: Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma missed.Item Economic evaluation of screening for open angle glaucoma(Cambridge University Press, 2008) Hernández, Rodolfo Andrés; Burr, Jennifer Margaret; Vale, Luke David; OAG Screening Project Group; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health SciencesObjectives: The aim of this study was to assess the cost-effectiveness of screening for open-angle glaucoma (OAG) in the United Kingdom, given that OAG is an important cause of blindness worldwide. Methods: A Markov model was developed to estimate lifetime costs and benefits of a cohort of patients facing, alternatively, screening or current opportunistic case finding strategies. Strategies, varying in how screening would be organized (e.g., invitation for assessment by a glaucoma-trained optometrist [GO] or for simple test assessment by a technician) were developed, and allowed for the progression of OAG and treatment effects. Data inputs were obtained from systematic reviews. Deterministic and probabilistic sensitivity analyses were performed. Results: Screening was more likely to be cost-effective as prevalence increased, for 40 year olds compared with 60 or 75 year olds, when the re-screening interval was greater (10 years), and for the technician strategy compared with the GO strategy. For each age cohort and at prevalence levels of ≤1 percent, the likelihood that either screening strategy would be more cost-effective than current practice was small. For those 40 years of age, “technician screening” compared with current practice has an incremental cost-effectiveness ratio (ICER) that society might be willing to pay when prevalence is 6 percent to 10 percent and at over 10 percent for 60 year olds. In the United Kingdom, the age specific prevalence of OAG is much lower. Screening by GO, at any age or prevalence level, was not associated with an ICER < £30,000. Conclusions: Population screening for OAG is unlikely to be cost-effective but could be for specific subgroups at higher risk.Item Survival from Uveal Melanoma in England and Wales 1986 to 2001(Informa, 2007-01) Burr, Jennifer Margaret; Mitry, E.; Rachet, B.; Coleman, M.P.Purpose. To analyse survival from uveal melanoma diagnosed in England and Wales during 1986-1999 and followed up to 2001. Methods. Data from the National Cancer Registry at the Office for National Statistics were analysed. The data were compiled from population-based cancer registries covering all of England and Wales for all adults (aged 15-99) diagnosed with primary ocular malignancy, excluding eyelid tumours. Level of poverty was based on the national classification of area of residence at time of diagnosis. Regression models explored the influence of sex, age and level of poverty on relative survival for patients diagnosed with uveal melanoma during successive calendar periods. Results. Of 5,519 adults identified with primary ocular malignancy, 4,717 had melanoma, of which 4,308 (91%) were eligible for analysis. Two-thirds (67%) of the ocular melanomas were uveal, 5% conjunctival and 2% orbital; the sub-site was unspecified in 26%. Relative survival from uveal melanoma was 95% at one year and 72% at five years. There was no statistically significant variation in one-year or five-year survival by sex or poverty level, and no significant trend over time. Older patients had significantly worse survival (P<0.001). Conclusions. This study provides national population-based survival estimates for England and Wales for uveal melanoma, the most common primary intraocular malignancy in adults. Five-year relative survival, an important indicator of the quality of cancer care, has not improved since the 1980s. Greater age, but not gender or level of poverty, is associated with a poorer prognosis. A standardised classification of uveal melanoma is required to improve reporting to cancer registries. Further research is required to explore reasons for lower relative survival in older persons.Item The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma : a systematic review and economic evaluation(Gray Publishing, 2007-10) Burr, Jennifer Margaret; Mowatt, Graham; Hernández, Rodolfo Andrés; Siddiqui, Muhammad Ardul Rehman; Cook, Jonathan Alistair; Lourenco, Tania; Ramsay, Craig R; Vale, Luke David; Fraser, Cynthia Mary; Azuara-Blanco, Augusto; Deeks, J.; Cairns, J.; Wormald, R.; McPherson, S.; Rabindranath, K.; Grant, Adrian Maxwell; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health SciencesObjectives: To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research. Data sources: Major electronic databases were searched up to December 2005. Review methods: Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken. Results: Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3–4% in 40 year olds with a screening interval of 10 years to approach costeffectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as £669. If annual societal costs were £8800, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of £30,000 per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty. In particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective. Conclusions: While population screening is not costeffective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing.Item Lens Extraction for Primary Angle Closure Glaucoma : a rapid systematic review(2007-09-07T15:28:19Z) Burr, Jennifer Margaret; Fraser, Cynthia Mary