A randomised controlled equivalence trial to determine the effectiveness and cost-utility of manual chest physiotherapy techniques in the management of exacerbations of chronic obstructive pulmonary disease (MATREX).

OBJECTIVES: To estimate the effect, if any, of manual chest physiotherapy (MCP) administered to patients hospitalised with chronic obstructive pulmonary disease (COPD) exacerbation on both disease-specific and generic health-related quality of life. To compare the health service costs for those receiving and not receiving MCP. DESIGN: A pragmatic, randomised controlled trial powered for equivalence. It was not possible to blind participants, clinicians or research staff to study arm allocation during the intervention. SETTING: Four UK hospitals in Norwich, Great Yarmouth, King's Lynn and Liverpool. PARTICIPANTS: 526 participants aged 34-91 years were recruited between November 2005 and April 2008; of these, 372 provided evaluable data for the primary outcome. All persons hospitalised with COPD exacerbation and evidence of sputum production on examination were eligible for the trial providing there were no contraindications to performing MCP. INTERVENTIONS: Participants were allocated to either MCP or no MCP on an intention-to-treat (ITT) basis. However, active cycle of breathing techniques (ACBT) was used in both arms. Participants allocated to the intervention were guided to perform ACBT while the physiotherapist delivered MCP. Participants allocated to the control arm received instruction on ACBT only. MAIN OUTCOME MEASURES: The primary outcome was COPD-specific quality of life, measured using the St George's Respiratory Questionnaire (SGRQ) at 6 months post randomisation. The European Quality of Life-5 Dimensions (EQ-5D) questionnaire was used to calculate the quality-adjusted life-year (QALY) gain associated with MCP compared with no MCP. Secondary physiological outcome measures were also used. RESULTS: Of the 526 participants, 261 were allocated to MCP and 264 to control, with 186 participants evaluable in each arm. ITT analyses indicated no significant difference at 6 months post randomisation in total SGRQ score [adjusted effect size (no MCP - MCP) 0.03 (95% confidence interval, CI -0.14 to 0.19)], SGRQ symptom score [adjusted effect size 0.04 (95% CI -0.15 to 0.23)], SGRQ activity score [adjusted effect size -0.02 (95% CI -0.20 to 0.16)] or SGRQ impact score [adjusted effect size 0.02 (95% CI -0.15 to 0.18)]. The imputed ITT and per-protocol results were similar. No significant differences were observed in any of the outcome measures or subgroup analyses. Compared with no MCP, employing MCP was associated with a slight loss in quality of life (0.001 QALY loss) but lower health service costs (cost saving of 410.79 pounds). Based on these estimates, at a cost-effectiveness threshold of lambda = 20,000 pounds per QALY, MCP would constitute a cost-effective use of resources (net benefit = 376.14 pounds). There was, however, a high level of uncertainty associated with these results and it is possible that the lower health service costs could have been due to other factors. CONCLUSIONS: In terms of longer-term quality of life the use of MCP did not appear to affect outcome. However, this does not mean that MCP is of no therapeutic value to patients with COPD in specific circumstances. Although the cost-effectiveness analysis suggested that its use was cost-effective, much uncertainty was associated with this finding and it would be difficult to justify providing MCP therapy on the basis of cost-effectiveness alone. Future research should include evaluation of MCP for patients with COPD producing high volumes of sputum, and an evaluation of the effectiveness of ACBT in COPD exacerbation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13825248.

Comparison of hydrocellular foam and calcium alginate in the healing and comfort of split-thickness skin-graft donor sites.

This is a comparative study of a hydrocellular foam (Allevyn, Smith and Nephew) and a calcium alginate (Kaltostat, ConvaTec) in dressing split-thickness skin-graft donor sites. The dressing materials were used in equal halves of each donor site in 20 patients undergoing skin-graft harvest. The donor sites dressed with Allevyn showed a tendency to earlier healing, but this was not confirmed statistically. However, Allevyn was found to be more comfortable than Kaltostat and this difference was statistically significant. Due to its increased patient comfort, cheaper cost and comparable time to healing with Kaltostat, the authors recommend the use of Allevyn as a dressing for split-thickness skin-graft donor sites.

Who gets priority? Waiting list assessment using a scoring system.

This study examines the relationship between clinical priority and duration on the waiting list. Patients' priority is also compared from three different perspectives: the consultant at out-patients (clinical urgency), the general practitioner who later sends a letter requesting expedition of admission (clinical urgency) and the 18-month waiters. Clinical priority in 222 patients awaiting primary hip or knee arthroplasty was assessed using a modification of the New Zealand priority criteria scoring system, administered by postal questionnaire. There was no correlation between time on waiting list and clinical score (r = 0.0). The hip and knee patient scores were not significantly different. The mean scores in the consultant and GP groups were higher (greater pain and disability) than in the 18-month waiters. The Kappa inter-rater agreement method demonstrated that both groups of clinician's assessment of clinical urgency had a 'fair' strength of agreement with scoring system, but the agreement of the 18-month waiter group was 'very poor'. Time on a waiting list should not be a decisive factor in establishing priority for primary hip or knee arthroplasty. Scoring systems can aid in assigning clinical priority for operation and indeed for the initial out-patient referral.

Tuberculosis mortality in England and Wales during 1982-1992: its association with poverty, ethnicity and AIDS.

This paper seeks to establish the strength of association between contemporary tuberculosis (TB) in England and Wales and several potential aetiological factors. It presents an ecological analysis of standardised annual TB mortality rates for the 403 local authority districts between 1982 and 1992, disaggregated by age and sex. Social, demographic and ethnicity measures from the 1981 and 1991 censuses and standardised annual AIDS-related mortality rates for young men are used to calculate Poisson regression models. A strong association was found between all TB mortality groups and overcrowding at the household level. For women, no other measures improved the explanatory power of the models. In multiple regressions, both poverty and AIDS-related mortality explained additional variation in the model for younger men. The link between ethnicity and tuberculosis notifications was not reflected in this analysis of mortality. For all groups no evidence of a positive relationship with ethnicity was found, once overcrowding had been accounted for. The significance of household as opposed to district level crowding suggests that prolonged contact is required for disease transmission. Regression analysis indicates that it is the overcrowding and poverty among ethnic populations that is significant for their tuberculosis mortality. The fact that the relationship between AIDS and TB is confined to the group most typical of AIDS patients provides evidence that AIDS has little influence on the level of tuberculosis mortality in the wider population. Explanations for the observed relationship include preferential certification, migration for treatment and shortcomings in health care provision.