National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma.

Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.

Clinical results and 10-year survivorship of the Synthes Epoca resurfacing total shoulder arthroplasty.

Aims: This prospective cohort study reports the 10-year survivorship, patient-reported outcome measures and radiographic outcomes of the first series of the Epoca resurfacing head total shoulder arthroplasty. Methods: From July 2008 to July 2014, 59 Epoca resurfacing head total shoulder arthroplasties were implanted in 50 patients by a single surgeon. Minimum 4.8 year and maximum 11.3 year follow-up (mean: 7.9 years) was analysed using the latest available Oxford Shoulder Score. Kaplan-Meier survivorship analysis was performed with revision as the end point. Most recent radiographs were reviewed for component radiolucency, osteolysis and proximal humeral migration. Results: Two shoulders underwent revision (3.4%); one for pain with posterior subluxation following a fall, the other for pain with failure of the glenoid. Kaplan-Meier analysis revealed 10-year survivorship of 98.2% (95% confidence intervals: 88.0%-99.8%). Mean Oxford Shoulder Score improved significantly compared to pre-operative values from 18.2 (5-45) to 46.6 (36-48) (p < 0.001). Fifty-three shoulders underwent radiographic analysis (89.8%). This revealed humeral radiolucency in two cases (3.8%), glenoid radiolucency in three cases (5.7%) and radiographic rotator cuff failure in eight cases (15.1%). Conclusion: This prospective cohort study shows excellent 10-year survivorship, medium to long-term clinical and radiological results and for the Synthes Epoca resurfacing head total shoulder arthroplasty. Evidence level: IV.

Stroke rehabilitation: long-term rehabilitation after stroke.

Many stroke survivors, despite improvements in mortality and morbidity, remain dependent on others for everyday activities. People with stroke need access to effective specialist multidisciplinary rehabilitation services that are organised and integrated within the whole system of health and social care. They also commonly come under the care of generalists in various clinical contexts, including intercurrent illness. This Clinical Medicine Concise Guideline abstracts key recommendations from the National Institute for Health and Care Excellence Clinical Guideline 162 on stroke rehabilitation of particular relevance to clinicians in general medicine, to inform their front-line practice and promote liaison and collaboration with the specialist service.

Do published search filters to identify diagnostic test accuracy studies perform adequately?

OBJECTIVES: To assess the performance of published search filters in finding diagnostic test accuracy studies. METHODS: Diagnostic test accuracy search filters were identified by searching medline, our own files and by requesting unpublished filters from colleagues. We applied the filters to a case study review of diagnostic test accuracy studies for urinary tract infections (UTI) in young children. The included studies with records in medline formed the gold standard. The performance of the filters in finding those gold standard records was assessed. RESULTS: We identified twenty-three diagnostic test accuracy search filters for use with medline. The case study systematic review of UTI included 179 studies of diagnostic test accuracy, of which 160 were available in medline. The filters showed a wide range of sensitivities (range: 20.6% to 86.9%) and precision (range: 1% to 9.4%). CONCLUSIONS: Our results broadly support those reported in two other studies. The search filters tested do not offer an adequate trade-off between sensitivity and precision to be used to identify studies for systematic reviews. However, there are methods available to explore whether search filters are viable based on an objective statistical analysis of the text and indexing used in records.

Need for high-quality studies in health technology assessments: the case of a systematic review of treatment for retinoblastoma.

OBJECTIVES: The aim of this study was to conduct a systematic review of the evidence for treatments for retinoblastoma in children. METHODS: Seventeen electronic databases were searched. Two reviewers independently selected studies. Studies of participants diagnosed with childhood retinoblastoma, any interventions, and all clinical outcomes were eligible. Randomized and nonrandomized controlled trials and cohort studies with clear comparisons between treatment groups were included. Methodological quality was assessed. RESULTS: Thirty-one observational comparative studies were included, of which twenty-seven were retrospective. The methodological quality was generally poor, with a high risk of selection bias in all studies. Although there were high levels of treatment success in many of the studies, due to the limitations of the evidence identified, it was not possible to make meaningful and robust conclusions about the relative effectiveness of different treatment approaches for retinoblastoma in children. CONCLUSIONS: Good quality randomized controlled trials are required. Where controlled trials are not feasible, only high quality prospective, nonrandomized studies should be given consideration, due to the generally higher risk of bias in retrospective studies.

Cost-effectiveness of interventions to support self-care: a systematic review.

OBJECTIVES: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness. METHODS: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions. RESULTS: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods. CONCLUSIONS: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.