New and updated summaries

Administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended.

Sanchez-Manuel FJ;Lozano-García J;Seco-Gil JL — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL

The use of antibiotic prophylaxis for elective hernia repair is currently a controversial issue. Although elective hernia repair is considered a clean procedure, the rate of postoperative wound infection in many countries exceeds the one expected for clean surgery, increasing discomfort in patients and health care expenses. In addition, antibiotics administration is not exempt of potential risks.
Controlled clinical trials on the use of antibiotic prophylaxis for hernia repair are scarce, the number of patients studied is low and the results are diverse. Based on the results of this meta-analysis of randomised clinical trials, administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. Neither can the administration be recommended when high rates of wound infection are observed.

Adenosine versus intravenous calcium channel antagonists for tachycardia in adults

Holdgate A;Foo A — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Holdgate A, Foo A

Supraventricular tachycardia (SVT)is a common abnormal rhythm of the heart resulting in a very rapid heart beat. This rhythm problem usually occurs in otherwise healthy people and common symptoms include palpitations, light headedness, and chest pain. Occasionally, SVT may also cause confusion or loss of consciousness. SVT can sometimes be treated with simple physical manoeuvres such as forced breath holding. When simple manoeuvres fail, supraventricular tachycardia can be treated in the Emergency department with a variety of different drugs. The two most commonly used drug types are adenosine and calcium channel antagonists (verapamil is the most frequently used drug in this class). This updated review compares the relative effectiveness and side effects of these two drugs.

Ten trials involving 805 patients were included in this review. Combined analysis of these trials showed no difference in the effectiveness of adenosine and verapamil in successfully treating supraventricular tachycardia, with an overall success rate of approximately 90% for both drugs. Adenosine took less time than verapamil to work, but when effective, both drugs worked within 15 minutes. Adenosine was associated with more unpleasant side effects than verapamil, with approximately one in ten patients treated with adenosine experiencing chest pain, nausea, shortness of breath or headache, while these symptoms occurred in less than 1% of patients treated with verapamil. However these side effects lasted for only a short time, usually less than a few minutes. Very low blood pressure which required treatment was reported in four out of 214 patients treated with verapamil, while no patients treated with adenosine experienced low blood pressure. Approximately 5% of patients may have only a temporary response to treatment with adenosine and require a second treatment.

Overall, both drugs appear to be similarly effective but adenosine is associated with a relatively high incidence of 'minor' side effects and verapamil is associated with infrequent 'major' side effects. None of the trials examined patient satisfaction with treatment or how long patients had to stay in hospital, and this somewhat limits the significance of the findings as these issues are probably most important in deciding which drug is the 'best' treatment.

Administering antimalarial drugs to prevent malaria in children during the malaria transmission season

Meremikwu MM;Donegan S;Sinclair D;Esu E;Oringanje C — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C

In areas where malaria is common, younger children have repeated episodes of malarial illness, which can sometimes be severe and life-threatening. In areas where malaria is seasonal, a practical policy option is to give drugs to prevent malaria at regular intervals during the transmission season, regardless of wether the child has malaria symptoms or not. This is known as Intermittent Preventive Treatment (IPTc).

The authors identified seven trials (12,589 participants); all were conducted in West Africa, and six of seven trials were restricted to children aged less than 5 years. The results show IPTc prevents three quarters of all malaria episodes, including severe episodes, and probably prevents some deaths.

Several antimalarial drugs or combinations have been tried, and shown to be effective. The most studied is amodiaquine plus sulphadoxine-pyrimethamine (AQ+SP). This combination probably doesn't have serious side effects but does cause vomiting in some children.

Advance distribution of misoprostol for preventing and treating excessive blood loss after birth

Oladapo OT;Fawole B;Blum J;Abalos E — Wed, 15 Feb 2012 00:00:00 +0100

New

Oladapo OT, Fawole B, Blum J, Abalos E

Excessive blood loss after birth remains an important cause of severe ill health and death of mothers particularly in settings where births still occur at home. The commonly used drugs (oxytocin and ergometrine) that help to reduce blood loss by making the womb contract immediately after birth need to be given by injection, and therefore cannot be used in the absence of a trained health professional. They also need to be stored in the refrigerator to remain effective. Misoprostol, another drug that helps the womb to contract strongly after birth, has an advantage over oxytocin and ergometrine because it is almost as effective, can be given by mouth and does not have any special storage requirements. Its side effects (particularly fever and shivering) are often minor and self-limiting and so do not require any additional medication. For these reasons, misoprostol could be used by lay health workers and the women themselves or a family member in places where births outside of a health facility are the norm. In some remote parts of the world where home birth is unavoidable, providing misoprostol well ahead of labour and childbirth to lay health workers and pregnant women themselves for self-use has recently become an attractive approach to ensure that the drug is available to the women who need it at the point of birth. However, there are concerns that misoprostol provided in this way may cause harm to the mother and her baby if used for other purposes such as starting labour or terminating a pregnancy. This review set out to determine whether increasing access to misoprostol by providing it ahead of labour and childbirth to lay individuals makes a difference to the health of the mother and her baby. The review found that no randomised trials had been conducted on this topic. There is therefore insufficient evidence to support a system of distributing misoprostol ahead of labour and childbirth within the community for preventing or treating excessive blood loss after birth.

Alginate dressings for healing foot ulcers in people with diabetes mellitus

Dumville JC;O'Meara S;Deshpande S;Speak K — Wed, 15 Feb 2012 00:00:00 +0100

New

Dumville JC, O'Meara S, Deshpande S, Speak K

Diabetes mellitus, a condition which leads to high blood glucose concentrations, is a common condition with around 2.8 million people affected in the UK (approximately 4.3% of the population). Wound dressings are widely used to treat foot ulcers in people with diabetes. There are many types of dressings that can be used, which also vary considerably in cost. This review (six studies involving a total of 375 participants) identified no research evidence to suggest that alginate wound dressings are more effective in healing diabetic foot ulcers than other types of dressing. More, better quality research is needed.

Aloe vera for treating acute and chronic wounds

Dat AD;Poon F;Pham KBT;Doust J — Wed, 15 Feb 2012 00:00:00 +0100

New

Dat AD, Poon F, Pham KBT, Doust J

Aloe vera is a cactus-like, succulent plant which grows in tropical climates. Aloe vera is widely used in a variety of cosmetics including creams and toiletries. Some studies conducted in animals have suggested that Aloe vera may help wound healing. Aloe vera can be applied topically as a cream or gel, or can be impregnated into a dressing and applied to the wound.
The authors of this Cochrane Review wanted to find evidence on whether Aloe vera encourages wound healing in people with acute wounds (for example lacerations, surgical incisions and burns) and chronic wounds (for example infected wounds, arterial and venous ulcers). The review found that there was not enough research evidence to answer this question.

Antibiotics for covert bacteriuria in children

Fitzgerald A;Mori R;Lakhanpaul M — Wed, 15 Feb 2012 00:00:00 +0100

New

Fitzgerald A, Mori R, Lakhanpaul M

Covert bacteriuria occurs when bacteria are found in urine either during routine screening or incidentally during other investigations. Unlike urinary tract infections, children with covert bacteriuria do not appear to have symptoms at the time of diagnosis. There is uncertainty about whether antibiotic treatment can help to clear infection, reduce recurrence, or prevent kidney damage. Any harmful effects of providing treatment also need to be identified and understood.

We identified three studies reporting the results on 460 girls. There was insufficient evidence about the harms and benefits of treatments to draw reliable conclusions, but it appears that antibiotic treatment is not likely to benefit children in the long term.

Antibiotics for the treatment of leptospirosis

Brett-Major DM;Coldren R — Wed, 15 Feb 2012 00:00:00 +0100

New

Brett-Major DM, Coldren R

Leptospirosis is a common disease both in the developed and developing world. It is caused by a bacteria spread by the urine of animals. People travelling, agricultural field workers, hunters, homeless, and others with close animal contact are groups that, in particular, can get leptospirosis. Like many common infections, most people infected with this disease do not feel sick. When people do feel sick, in some instances up to 1 out of every 10 people have died. Whether or not antibiotics should be used, and if used which antibiotic should be used have been matters for debate for many years. This review identified and assessed seven clinical trials that tested antibiotics in patients sick with leptospirosis. Four of these trials compared intravenous penicillin to a placebo. Three of the trials looked at differences between different antibiotics. All trials had high risk of systematic errors (bias) and of random errors (play of chance). When looked at together, these trials do not answer the basic questions about whether or not antibiotics should be used. Part of the reason for this is that there is a wide range of severity among people ill with the disease. Additional randomised clinical trials are needed. Nonetheless, these trials suggest that antibiotics administered to patients who are sick with leptospirosis may make patients feel better two days earlier than they otherwise would have improved. However, it is also possible that when patients are severely ill, penicillin therapy might increase the risk of death or dialysis in comparison to those who receive no antibiotics. Other antibiotics have not been tested in this way. Despite the lack of evidence, if a clinician chooses to treat leptospirosis with an antibiotic, there does not seem to be any difference between the appropriate use of intravenous penicillin, intravenous cephalosporin, doxycyline, or azithromycin. But, for this they have not been tested to the same extent as intravenous penicillin.

Antipsychotic drugs for elderly people with late-onset schizophrenia

Essali A;Ali G — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Essali A, Ali G

A significant proportion of the world's growing elderly population suffers from schizophrenia that started very late in life. Antipsychotic drugs are often used to treat this distressing and severe illness. In this review we attempted to find good quality trial-based evidence to support this practice but found none. Currently this vulnerable group is not well served by the research community.

Aspirin, steroid and non-steroidal anti-inflammatory drugs use for treating Alzheimer's disease

Jaturapatporn D;Isaac MGEKN;McCleery J;Tabet N — Wed, 15 Feb 2012 00:00:00 +0100

New

Jaturapatporn D, Isaac MGEKN, McCleery J, Tabet N

Inflammation may play an important role in the development of Alzheimer’s disease. There is also some evidence from community surveys that people receiving anti-inflammatory drugs for various medical conditions may be less likely to develop Alzheimer's disease. Fourteen studies met our inclusion criteria for this review and none of the exclusion criteria. Aspirin, steroid and non-steroidal anti-inflammatory drugs (NSAIDs) (traditional and the selective cyclooxygenase-2 (COX-2) inhibitors) showed no significant benefit in the treatment of Alzheimer's disease. Therefore, the use of these drugs cannot be recommended for the treatment of Alzheimer's disease.

Behavioral interventions to reduce HIV incidence and HIV/STI prevalence among female sex workers in low- and middle-income countries

Wariki WMV;Ota E;Mori R;Koyanagi A;Hori N;Shibuya K — Wed, 15 Feb 2012 00:00:00 +0100

New

Wariki WMV, Ota E, Mori R, Koyanagi A, Hori N, Shibuya K

The rates of human immunodeficiency virus (HIV) and sexually transmitted infection (STI) transmission continue to increase, particularly among sex workers and their clients in low- and middle-income countries. Prevention efforts directed towards these infections in this at-risk population may have had an effect in reducing the overall transmission of HIV/STIs in the general population. Several successful behavioral interventions have been reported including interventions to reduce HIV/STI incidence and prevalence, change behavior, promote condom use, improve condom availability, and increase sexual health knowledge. The review found seven individual randomised controlled trials (RCTs), two cluster-RCTs and four quasi-RCTs involving 8,698 participants examining a variety of behavioral interventions to evaluate whether they reduced HIV/STIs rates or resulted in changed behavior among sex workers and their clients. Results showed that the interventions were effective in HIV/STI prevention, including reducing the incidence and prevalence of HIV and STIs. Furthermore, there were some differences in self-reported behavior including increased condom use and a reduction in the risk of drug use. However, these trials were small and generally had few participants. As a result, evidence for the effectiveness of social cognitive theory and promoting condom use in reducing HIV/STI incidence compared to other behavioral interventions was limited, because no RCTs examined the effects of these interventions on HIV prevalence or on sex workers other than FSWs. In future research and program agendas therefore it is important to assess other potentially more potent behavioral change strategies.

Birth control pills with drospirenone for treating premenstrual syndrome

Lopez LM;Kaptein AA;Helmerhorst FM — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Lopez LM, Kaptein AA, Helmerhorst FM

Premenstrual syndrome (PMS) is a common problem. A severe form is called premenstrual dysphoric disorder (PMDD). Birth control pills with the hormones progestin and estrogen have been studied for treating such symptoms. A birth control pill with the progestin drospirenone may work better than other such pills. A drospirenone pill with low estrogen was approved for treating PMDD, the severe form of PMS, in women who use birth control pills.

We did a computer search for trials that compared a birth control pill containing drospirenone and estrogen to a placebo ('dummy') or another birth control pill in treating premenstrual symptoms. We wrote to researchers to find other trials. We looked at whether the pills reduced symptoms and if side effects were reported. Women recorded their symptoms over time.

We found five trials with 1920 women. Two trials compared a dummy pill to a drospirenone pill with low estrogen. All the women had PMDD, the severe form of PMS, before the trial. After three months, women on the drospirenone pill with low estrogen had less severe premenstrual symptoms than the group taking the dummy pill. Women in the drospirenone group said they could do more and had more social activities and friends. Women on the drospirenone pill had more nausea, bleeding between periods, and breast pain. These side effects are common with birth control pills. Three trials studied a drospirenone pill with more estrogen for treating less severe symptoms. These women did not all have PMDD. One compared the drospirenone pill to a dummy pill but did not have enough data for our review. Two compared the study pill to another birth control pill. The two-year study showed the groups were similar for premenstrual symptoms and side effects. The six-month study did not give enough data on the symptoms.

A drospirenone pill with low estrogen seems to help premenstrual symptoms in women with severe symptoms (PMDD). The drospirenone pill worked a little better than the dummy pill, which also affected symptoms. We do not know if the birth control pill works longer than three cycles, helps women with less severe symptoms, or is better than other birth control pills. Longer and better studies with more women are needed to address these issues. Trials reports should be clearer about how the study was done.

Blood transfusion for anaemia in patients with advanced cancer

Preston NJ;Hurlow A;Brine J;Bennett MI — Wed, 15 Feb 2012 00:00:00 +0100

New

Preston NJ, Hurlow A, Brine J, Bennett MI

Many patients admitted to a hospice are anaemic but only a small proportion receive a blood transfusion. Two of the main symptoms of anaemia are fatigue and breathlessness. This review aimed to identify whether blood transfusion was a useful treatment for patients with advanced cancer who were anaemic. We identified only 12 relevant studies but all were of low quality. They indicated that fatigue and breathlessness improved immediately after the transfusion but this began to wane after a period of two weeks. Of those receiving a transfusion, 31% to 70% had a transient benefit that lasted about two weeks.

Bone agents for breast cancer

Wong MHF;Stockler MR;Pavlakis N — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Wong MHF, Stockler MR, Pavlakis N

When breast cancer (BC) has spread to the bones (bone metastases, BM), bone agents (added to anti-cancer treatment for breast cancer) can reduce pain, fractures and other bone problems. Women and men with advanced breast cancer (ABC) commonly develop bone metastases. Cancer in bones can cause pain, fractures, hypercalcaemia (too much calcium in the blood) and tumour compression of the spinal cord, resulting in serious and permanent nerve damage. This is because cancer deposits can erode into bone using bone-absorbing cells. Bisphosphonates, and the more recent novel targeted-therapy denosumab, are drugs that reduce the activity of these bone-absorbing cells. This review of trials in women with advanced BCBM found that the use of bisphosphonates or denosumab (in addition to their other cancer treatments), can reduce these serious bone problems. It is of great interest to see if bisphosphonates prevent recurrence and improve survival for patients who have been treated for early breast cancer (EBC). However, this review of trials in women with EBC has not identified a benefit of bisphosphonates as an adjuvant therapy at this stage. We have to wait for the reporting of a number of large clinical trials before firm conclusions can be made. Adverse effects are not common for bisphosphonates and include mild gut reactions, transient fever, hypocalcaemia and a small risk of osteonecrosis of the jaw (ONJ), depending on which drug is used. Denosumab appears to be at least as well tolerated as the bisphosphonates.

Botulinum toxin for the treatment of strabismus

Rowe FJ;Noonan CP — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Rowe FJ, Noonan CP

Strabismus is a condition in which the eyes are out of alignment; one eye may turn inwards, outwards, upwards or downwards. Strabismus may develop in childhood or may be acquired as an adult. Treatment options include eye therapy, glasses, prisms, occlusion, botulinum toxin or surgery, to reduce the deviation of the eyes. Currently there is no clear recommendation on the use of botulinum toxin in the treatment of strabismus.

This review found four randomised controlled trials that compared botulinum toxin to another treatment or to no treatment. The results showed no prophylactic use for botulinum toxin in sixth nerve palsy, poor effect in adult horizontal strabismus without binocular use of the eyes, and no difference in response for retreatment of infantile esotropia or acute onset esotropia. It was not possible to determine dose effect because of the different types and doses of botulinum toxin used in each trial. Complications from the use of botulinum toxin (Botox™ or Dysport™) included transient ptosis and vertical deviation and combined rates for these complications ranged from 24% to 55.54%. This review identified a need for more randomised controlled trials to provide further reliable evidence on the effective use of botulinum toxin for the treatment of strabismus.

Cabergoline to prevent ovarian hyperstimulation syndrome in women undergoing assisted reproduction technology

Tang H;Hunter T;Hu Y;Zhai S-D;Sheng X;Hart RJ — Wed, 15 Feb 2012 00:00:00 +0100

New

Tang H, Hunter T, Hu Y, Zhai S-D, Sheng X, Hart RJ

Ovarian hyperstimulation syndrome (OHSS) occurs as a result of ovulation induction in assisted reproduction technology (ART) treatment. In most cases the condition is mild, but some women get a moderate or severe form of OHSS. The symptoms range from abdominal bloating and a feeling of fullness to shortness of breath and severe abdominal discomfort. Despite measures adopted by physicians to prevent OHSS, these measures are purely preventative as there is no cure for OHSS other than awaiting spontaneous resolution and providing supportive measures. A dopamine agonist cabergoline has been introduced to try and reduce the risk of OHSS. This review included two trials with moderate risk of bias (involving 230 women) and found evidence that an oral dose of 0.5 mg cabergoline daily may reduce the risk of OHSS in high-risk women, especially moderate OHSS. It had no influence on the pregnancy outcome.

Calcitonin used to treat metastatic bone pain

Martinez-Zapata MJ;Roqué i Figuls M;Alonso-Coello P;Roman Y;Català E — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Martinez-Zapata MJ, Roqué i Figuls M, Alonso-Coello P, Roman Y, Català E

The limited evidence currently available does not support the use of calcitonin to control pain arising from bone metastases. People who have cancer which has spread to their bones and the nerves adjacent to the bones often suffer severe pain. There are several treatments to help relieve this pain: radiotherapy, analgesic (pain-relieving) drugs such as opioids and bone-modulating drugs such as bisphosphonates and calcitonin. Calcitonin has the potential to relieve pain and maintain bone strength, thus reducing the risk of bone fractures. This review looked at the effectiveness of calcitonin for controlling pain from bone metastases. However, few studies were found and the evidence currently available does not support its use for patients suffering from bone pain. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered.

Can cognitive stimulation benefit people with dementia?

Woods B;Aguirre E;Spector AE;Orrell M — Wed, 15 Feb 2012 00:00:00 +0100

New

Woods B, Aguirre E, Spector AE, Orrell M

People with dementia and their caregivers are often advised that 'mental exercise' may be helpful in slowing down the decline in memory and thinking experienced by many people with dementia. This review examined the evidence for one form of mental exercise, described as cognitive stimulation. This involves a wide range of activities that aim to stimulate thinking and memory generally, including discussion of past and present events and topics of interest, word games, puzzles, music and practical activities such as baking or indoor gardening. Typically this is carried out by trained staff with a small group of four or five people with dementia for around 45 minutes at least twice a week. Family caregivers have also been trained to provide cognitive stimulation to their relative on a one-to-one basis.

This review included 15 trials with a total of 718 participants. The findings suggested that cognitive stimulation has a beneficial effect on the memory and thinking test scores of people with dementia. Although based on a smaller number of studies, there was evidence that the people with dementia who took part reported improved quality of life. They were reported to communicate and interact better than previously. No evidence was found of improvements in the mood of participants or their ability to care for themselves or function independently, and there was no reduction in behaviour found difficult by staff or caregivers. Family caregivers, including those who were trained to deliver the intervention, did not report increased levels of strain or burden.

The trials included people in the mild to moderate stages of dementia and the intervention does not appear to be appropriate for people with severe dementia. More research is needed to find out how long the effects of cognitive stimulation last and for how long it is beneficial to continue the stimulation. Involving family caregivers in the delivery of cognitive stimulation is an interesting development and merits further evaluation.

Can lobeline help people to quit smoking

Stead LF;Hughes JR — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Stead LF, Hughes JR

Lobeline is an alkaloid derived from the leaves of an Indian tobacco plant, and has been widely used in commercial smoking remedies. Its adverse effects include dizziness, nausea, and vomiting, and tablets and pastilles containing Lobeline may lead to throat irritation. The review found no adequate long-term trials which could provide evidence that Lobeline can help people stop smoking. One large study with only s ix weeks follow-up did not detect any evidence of short-term b enefit , suggesting that lobeline is not an e ffective treatment.

Can organisational infrastructures be effective in promoting evidence-based nursing practice?

Flodgren G;Rojas-Reyes MX;Cole N;Foxcroft DR — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Flodgren G, Rojas-Reyes MX, Cole N, Foxcroft DR

Nurses and midwives form the bulk of the clinical health workforce, and play a central role in all health service delivery. There is potential to improve health care quality if nurses routinely use the best available evidence in their clinical practice. Since many of the factors perceived by nurses as barriers to the implementation of evidence-based practice (EBP) lie at the organisational level, it is of interest to devise and assess the effectiveness of models to change healthcare organisations in order to promote the use of EBP among nurses successfully.

We defined organisational infrastructures as being "the underlying foundation or basic framework through which clinical care is delivered and supported", which include for example: organisational policies, nurse development units and other types of organisational developments such as organisations developing and implementing evidence-based nursing procedures, standards or guidelines for clinical practice.

We searched the literature for robust evaluations of the effectiveness of organisational interventions in promoting EBP in nursing. We included one study from the USA which involved one hospital and for which the number of nurses was not reported. The study evaluated the effects of a standardised evidence-based nursing procedure on improved nursing care for patients at risk of developing healthcare-acquired pressure ulcers (HAPUs), as measured by the HAPU rate. If a patient's admission Braden score was lower than or equal to 18, nurses were authorised to initiate a prevention pressure ulcer care bundle, without a physician order. The Braden scale is a tool used to assess a patient's risk of developing pressure ulcers. An adult with a score below or equal to 18 is considered to have a high risk for developing a pressure ulcer.

Re-analysis of the HAPU data, as an interrupted time series, was suggestive of a trend in rates prior to intervention and, if that trend was assumed to be real, there was no evidence of an intervention effect at three months (mean rate per quarter 0.7%; 95% confidence interval (CI) 1.7 to 3.3; P = 0.457). Given the small percentages post intervention it was not statistically possible to extrapolate effects beyond three months.

Considering the importance placed on organisational change in promoting EBP in nursing, it is surprising that eight years after the previous empty Cochrane review was published, appropriately evaluated organisational infrastructure interventions are still lacking. If policy-makers and healthcare organisations wish to promote evidence-based nursing at an organisational level successfully, they must ensure the funding and conduct of well-designed studies to generate evidence to guide policy.

Cancer genetic risk assessment for individuals at risk of familial breast cancer

Hilgart JS;Coles B;Iredale R — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Hilgart JS, Coles B, Iredale R

The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, which resulted in the creation of genetic clinics for familial cancer. Cancer genetic services can involve extended counselling, specialist screening and genetic testing for mutations. Risk assessment is the first step in the process of providing information and support to patients and their families about their risk of inheriting cancer. Information on evidence-based methods of delivering cancer genetic risk-assessment services is, however, sparse. For this review a systematic search, review, and assessment of the literature on the delivery of cancer genetic risk-assessment services for individuals concerned with familial breast cancer was undertaken.

This review included eight trials (10 papers) which covered the process of risk assessment for familial breast cancer. These focused on the psychosocial impact on patients, as well as other outcomes and aspects of service delivery, and provided data on 1973 participants. Due to the limited number of trials, this review found insufficient evidence to make any firm conclusions about the best way to deliver risk-assessment services for individuals concerned about a family history of breast cancer. All eight included studies did, however, demonstrate improvements in psychological well-being and a decrease in the levels of cancer worry as a result of the risk-assessment service. Although limited, the findings of this review suggest that cancer genetic risk-assessment services can help to reduce distress, improve the accuracy of the individual's perceived risk of breast cancer, and increase knowledge about breast cancer and genetics. Existing evidence suggests that such services do not cause patients any harm and, in the short-term, can have a positive effect by helping to ease distress and decrease cancer worry. From this review, it does not appear that the health professional delivering the risk assessment has a significant impact on these outcomes.

Carbetocin for preventing postpartum haemorrhage

Su L-L;Chong Y-S;Samuel M — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Su L-L, Chong Y-S, Samuel M

In low- and middle-income countries, postpartum haemorrhage is a major cause of maternal deaths and ill health. In high-income countries, the problems are much less but there is still a small risk of major bleeding problems for women after giving birth. Active management of the third stage of labour, which is generally used to reduce blood loss at birth, consists of giving the mother a drug that helps the uterus to contract, early cord clamping and controlled cord traction to deliver the placenta. Different drugs have been tried and generally either intramuscular oxytocin or intramuscular syntometrine is given. Carbetocin is an oxytocin agonist. Oxytocin agonists are a group of drugs that mimic the oxytocin action, oxytocin being the natural hormone that helps to reduce blood loss at birth. This review includes 11 randomised controlled trials involving 2635 women. The trials compared carbetocin against either oxytocin or syntometrine given after delivery, vaginally or by caesarean section. The comparison between intramuscular carbetocin and oxytocin showed that women who had carbetocin were less likely to have heavy bleeding and less likely to require other medications to produce uterine contractions following caesarean sections. Comparisons between carbetocin and syntometrine showed that women who received carbetocin had less blood loss compared to women who received syntometrine after vaginal delivery, and were much less likely to experience side effects such as nausea and vomiting. The incidence of hypertension at 30 and 60 minutes post delivery was also significantly lower in women who received carbetocin compared to those who received syntometrine. Five of the 11 studies were known to be supported by a pharmaceutical company.

Carnitine supplements for treating people with inborn errors of metabolism

Nasser M;Javaheri H;Fedorowicz Z;Noorani Z — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Nasser M, Javaheri H, Fedorowicz Z, Noorani Z

Inborn errors of metabolism are genetic disorders which have a wide range of symptoms. These often start at or soon after birth but may appear first at any time during adulthood. Affected individuals may need to deal with symptoms of the disease throughout their lifetime. Symptoms are often non-specific and may affect any organ. It can be difficult to diagnose an inborn error of metabolism. However, early detection is important and screening of infants for some disorders, such as phenylketonuria, is routine in several countries. It is recommended that carnitine supplements are prescribed in the diet of individuals with certain inborn errors of metabolism, along with other standard treatments. Carnitine supplements take the form of tablet, oral liquid, paediatric liquid and injection and might be taken with food for ease of administration. Unfortunately, we did not find any good quality trials to include in the review. This does not mean that carnitine is ineffective or should not be used in treating inborn errors of metabolism; however, individuals receiving carnitine should be carefully observed and monitored. Therefore, we recommend that clinicians base their decision to prescribe carnitine on clinical experience together with individual preferences. Future trials should include patient-reported outcomes using validated and internationally recognised scales. Any adverse events associated with the treatment should be reported. It should be carefully considered whether placebo-controlled trials in potentially lethal diseases, e.g. carnitine transporter disorder or glutaric aciduria type I, are ethical.

Chest physiotherapy for acute bronchiolitis in children younger than two years of age

Roqué i Figuls M;Giné-Garriga M;Granados Rugeles C;Perrotta C — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Roqué i Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C

Acute bronchiolitis is a frequent viral respiratory infection in children younger than two years of age. Most children have a mild disease and do not require hospitalisation. Those who do need to be hospitalised sometimes have difficulty clearing phlegm (thick mucous respiratory secretions caused by the infection). It has been proposed that chest physiotherapy may assist in the clearance of the respiratory secretions and improve breathing. This review has not found any evidence that chest physiotherapy has a clinical benefit in infants with acute bronchiolitis.

In the nine trials identified, which included 891 participants, chest physiotherapy has not shown to reduce the length of disease, improve the clinical scores or reduce the hospital stay in comparison with no treatment. The included trials did not report any severe adverse events, although one of the trials reported a higher number of transient episodes of vomiting and respiratory instability after physiotherapy. The conclusions are robust although they are based on a small number of trials, because the results are consistent across the trials and consistent with a large trial with a low risk of bias.

Chinese medicinal herbs for acute bronchitis

Jiang L;Li K;Wu T — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Jiang L, Li K, Wu T

We assessed the therapeutic effect of traditional Chinese herbal medicines commonly used in China for acute bronchitis. There is no evidence from randomised controlled trials (RCTs) to demonstrate that Chinese medicinal herbs are efficacious in treating acute bronchitis.

We identified 74 studies involving 6877 participants which reported to randomly allocate participants to their treatment groups. However, we did not identify any true RCTs for inclusion. The common reasons for exclusion were a potential high risk of selection bias and conflict of interest. These design limitations resulted in us being unable to draw conclusions on the effects of Chinese herbal medicines for acute bronchitis. In addition, the safety of Chinese medicinal herbs is unknown due to the lack of toxicological evidence, although some adverse events, for example, slight gastrointestinal reactions, skin rash, etc., were reported in some case reports but not in the so called 'random' studies which we excluded. High quality RCTs are needed in the future.

Cold-water immersion for preventing and treating muscle soreness after exercise

Bleakley C;McDonough S;Gardner E;Baxter GDavid;Hopkins JTy;Davison GW — Wed, 15 Feb 2012 00:00:00 +0100

New

Bleakley C, McDonough S, Gardner E, Baxter GDavid, Hopkins JTy, Davison GW

Delayed onset muscle soreness commonly results after sports and exercise activity. Cold-water immersion (CWI), which involves people immersing themselves in water at temperatures of less than 15°C, is sometimes used to manage muscle soreness after exercise and to speed up recovery time.

Our review included 17 small trials, involving a total of 366 participants. Study quality was low. Fourteen trials compared cold-water immersion applied after exercise with 'passive' treatment involving rest or no treatment. The temperature, duration and frequency of cold-water immersion varied between the different trials as did the exercises and settings. There was some evidence that cold-water immersion reduces muscle soreness at 24, 48, 72 and even at 96 hours after exercise compared with 'passive' treatment. Limited evidence from four trials indicated that participants considered that cold-water immersion improved recovery/reduced fatigue immediately afterwards. Most of the trials did not consider complications relating to cold-water immersion and so we cannot say whether these are a problem. There were only limited data available for other comparisons of cold-water immersion versus warm or contrasting (alternative warm/cold) water immersion, light jogging, and compression stockings. None of these showed important differences between the interventions being compared.

While the evidence shows that cold-water immersion reduces delayed onset muscle soreness after exercise, the optimum method of cold-water immersion and its safety are not clear.

Combined hormone therapy is more effective than tibolone on menopausal symptoms. Tibolone may increase the risk of recurrent breast cancer and stroke

Wed, 15 Feb 2012 00:00:00 +0100

New

Formoso G, Perrone E, Maltoni S, Balduzzi S, D'Amico R, Bassi C, Basevi V, Marata AM, Magrini N, Maestri E

The authors analysed 33 clinical trials to evaluate whether tibolone, compared to placebo or combined hormone replacement therapy (HT), was effective in alleviating menopausal symptoms and the risks associated with the longer term use of HT. Limited evidence suggested that tibolone was less effective than combined HT in the treatment of menopausal symptoms, although fewer women suffered vaginal bleeding. In two separate trials, prolonged use of tibolone (for one or more years) increased the risk of breast cancer in women who had already suffered from breast cancer in the past and increased the risk of stroke in women whose mean age was over 60 years. The risk profile of this drug is not well defined but it is concerning enough that its longer term use should not be supported.

Comparing electronic monitoring of the baby's heartbeat on a woman's admission in labour using cardiotocography (CTG) with intermittent monitoring

Devane D;Lalor JG;Daly S;McGuire W;Smith V — Wed, 15 Feb 2012 00:00:00 +0100

New

Devane D, Lalor JG, Daly S, McGuire W, Smith V

Monitoring of the fetal heart rate (FHR) is one of the most common methods for checking a baby's wellbeing. The two most common ways of monitoring the FHR are by listening to the heart beat using a fetal stethoscope, Pinard (special trumpet shaped device), handheld Doppler ultrasound device (this is known as intermittent auscultation) or by an electronic fetal monitoring (EFM) machine that produces a paper printout of the baby’s heart rate and the mother’s contractions, called a cardiotocograph (CTG). The admission CTG is a commonly used test consisting of a short, usually 20 minute, recording of the FHR and uterine activity that is performed when the mother is admitted to the labour ward with signs of labour. The admission CTG was introduced to try and identify those babies who were at greatest risk of becoming compromised with a lack of oxygen during labour. These babies could be monitored more intensively by continuous electronic fetal monitoring, or they may benefit from an immediate intervention such as being delivered by caesarean section.

This review compared the admission CTG with intermittent auscultation of the FHR performed on the mother's admission to the labour ward. We included four randomised controlled trials involving more than 13,000 women with low-risk pregnancies in the review. Women allocated to admission CTG were more likely to have a caesarean section than women allocated to intermittent auscultation. There was no difference in the number of instrumental vaginal births or in the number of babies who died during or shortly after labour between women allocated to admission CTG and women allocated to intermittent auscultation. Admission CTG was associated with a significant increase in the use of continuous electronic fetal monitoring (with an electrode placed on the baby’s scalp) and fetal blood sampling (a small blood sample taken from a baby's scalp) during labour. There were no differences in other outcomes measured such as artificial rupture of the membranes, augmentation of labour or use of an epidural.

Cooling the brain during surgery for preventing death or severe disability in patients with brain aneurysms

Li LR;You C;Chaudhary B — Wed, 15 Feb 2012 00:00:00 +0100

New

Li LR, You C, Chaudhary B

Intracranial aneurysms are bulges on the cerebral arterial wall. Rupture of an intracranial aneurysm is often life-threatening. Such patients are classified as good-grade or poor-grade based on their clinical manifestations. Surgery is a common option to treat this problem but it can cause further damage to the brain. Theoretically, intraoperative mild hypothermia reduces the metabolic activity of the brain thus protecting it during an operation. Research on animals supports this theory in general. We conducted a systematic review on clinical trials examining the effect of intraoperative mild hypothermia in preventing death and handicap in patients undergoing open-skull surgery for cerebral aneurysms. We found only three randomised controlled trials with a total of 1158 patients for inclusion in the review. Data primarily came from one high-quality study with 1000 patients. Our analysis showed that, for patients with good-grade aneurysmal subarachnoid haemorrhage, intraoperative mild hypothermia may have the potential to prevent death or dependency in activities of daily living in a few of them. However, the effect cannot be proven statistically. Although no harm of intraoperative mild hypothermia was documented, this treatment should not be applied routinely. In patients with poor-grade aneurysmal subarachnoid haemorrhage or without subarachnoid haemorrhage, the effect is unclear. A high-quality randomised clinical trial of intraoperative mild hypothermia for postoperative neurological deficits in patients with poor-grade aneurysmal subarachnoid haemorrhage might be feasible.

Deferasirox for managing transfusional iron overload in people with thalassaemia

Meerpohl JJ;Antes G;Rücker G;Fleeman N;Motschall E;Niemeyer CM;Bassler D — Wed, 15 Feb 2012 00:00:00 +0100

New

Meerpohl JJ, Antes G, Rücker G, Fleeman N, Motschall E, Niemeyer CM, Bassler D

Thalassaemia is a hereditary anaemia due to a defect in the production of haemoglobin. Regular red blood cell transfusions are needed, particularly for the severe form of the disease, thalassaemia major. This results in secondary iron overload. Since the human body has no means of actively getting rid of excessive iron, drug treatment (iron chelators) is needed. Several years ago, a new oral iron chelator, deferasirox, was introduced. However, it is not known whether deferasirox offers advantages compared to deferoxamine or deferiprone with regard to effectiveness and safety.

Four studies are included in the review. Two studies comparing deferasirox with placebo showed effectiveness of deferasirox with regard to iron excretion. Two other studies compared deferasirox with standard treatment of deferoxamine. Similar effectiveness seems to be achievable depending of the doses and ratio of the two drugs compared. It needs to be confirmed whether this results in similar improvement of patient-important outcomes in the long run.

The safety of deferasirox was acceptable; however, rarer adverse events or long-term side effects could not be adequately investigated due to the limited number of patients and the short duration of the studies. Patient satisfaction was significantly better with deferasirox, while rate of discontinuations was similar for both drugs.

Deferasirox should be offered as an alternative to all patients who do not tolerate deferoxamine or who have poor compliance with deferoxamine. Ideally, further studies looking at patient-important, long-term outcomes as well as rarer adverse events should be conducted prior to routine recommendation of deferasirox as first line therapy in thalassaemia patients with iron overload.

Diclofenac with or without an antiemetic for acute migraine headaches in adults

Derry S;Rabbie R;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Derry S, Rabbie R, Moore RA

This review found that oral diclofenac potassium 50 mg was an effective treatment for migraine headache, reducing moderate to severe pain to no more than mild pain within two hours in about half (55%) of those treated, to no pain at two hours in about one in five (22%), and to no pain sustained to 24 hours in about the same number (19%). Based on very limited information, it appears that associated symptoms of nausea, photophobia and phonophobia were also relieved by diclofenac potassium. Adverse events were mostly self limiting and of mild or moderate intensity, and were not significantly different from placebo over the short term. Although diclofenac provided good outcomes for some patients, almost half did not experience adequate pain relief within two hours, and as few as one in five became pain-free. It is not clear whether the 100 mg dose provides good outcomes for more people. For those who do not experience adequate responses, a different therapy will be needed.

There was no information about different formulations of diclofenac (e.g. rectal) to treat acute migraine headaches.

Dietary supplements for established atopic eczema in adults and children

Bath-Hextall FJ;Jenkinson C;Humphreys R;Williams HC — Wed, 15 Feb 2012 00:00:00 +0100

New

Bath-Hextall FJ, Jenkinson C, Humphreys R, Williams HC

Eczema is a skin condition characterised by an itchy, red rash, which affects 5% to 20% of people worldwide. There is no cure, but many treatments can help improve the skin's condition, making life easier. In those for whom these treatments do not work well or who fear their long-term effects, there is often a belief that either something in their diet, or something missing in their diet, is making their eczema worse.

This review looked at the following dietary supplements (products which add ingredients to a diet): fish oil, zinc, selenium, vitamin D, vitamin E, pyridoxine (vitamin B6), sea buckthorn oil, hempseed oil, and sunflower oil.

Three commonly used dietary supplements (evening primrose oil, borage oil, and probiotics) are currently the subject of other Cochrane reviews (Boehm 2003; Boyle 2008).

We looked for trials comparing supplements with placebo (dummy). We included 11 randomised controlled trials (596 participants) when it was clear that the children or adults taking part had atopic eczema. In reviewing the trials, the main outcomes we looked for were evidence of improvement in the symptoms of eczema, such as itching or loss of sleep, in the short-term (i.e. six weeks). In the longer term, we wanted to see evidence of a reduced need for treatment for the eczema or a reduction in the number of flares. We also looked for evidence of any general improvement in the eczema and in individual symptoms.

Overall, we found no convincing evidence that taking supplements improved the eczema of those involved. In general, studies were small with low numbers of participants and of poor quality in terms of the way they were run. Two trials of fish oil did find slight improvement for the participants in terms of the degree of itchiness and quality of life. However, these trials had small numbers, which means they had little chance of finding real differences if they did exist. That is why larger trials are needed before any recommendations can be made. We found no evidence of adverse (harmful) effects in those who took part in the trials. People sometimes think that supplements can at least do no harm; however, high doses of vitamin D, for example, can cause serious medical problems, and the safety of dietary supplements should not be assumed. The cost of supplements can also mount up.

Different magnesium sulphate regimens given to women at risk of preterm birth to help protect the baby’s brain and improve long-term outcomes

Bain E;Middleton P;Crowther CA — Wed, 15 Feb 2012 00:00:00 +0100

New

Bain E, Middleton P, Crowther CA

This review found that not enough research has been carried out to show what is the best dose of, and how best to provide, magnesium sulphate to mothers prior to very preterm birth to protect the baby’s brain

Babies born early (preterm) are at an increased risk of dying, and those who survive are at risk of damage to the brain that may lead to cerebral palsy (a disorder that affects the ability to move normally), blindness, deafness or other disability. Magnesium is an important mineral essential for good health and normal body and brain function. High-quality evidence from a Cochrane review shows that giving magnesium sulphate therapy to the mother before birth can help protect the preterm baby’s brain and improve long-term outcomes for the infant as it grows.

Magnesium sulphate is given in different doses and in different ways. There are some adverse effects for the mother during therapy such as flushing, warmth, sweating, nausea and vomiting, which may vary by the dose and way the magnesium sulphate is given. Since there is no clear and agreed best way, hospitals may vary in how they give magnesium sulphate. We found no completed randomised trials comparing different magnesium sulphate regimens. Studies are needed to establish what is the best dose and best way to give the magnesium sulphate. The babies in these trials need to be followed up over a long period so that we can monitor the effects of magnesium on child development.

Does ultrasound treatment of broken bones in adults help improve bone healing times and reduce complications?

Griffin XL;Smith N;Parsons N;Costa ML — Wed, 15 Feb 2012 00:00:00 +0100

New

Griffin XL, Smith N, Parsons N, Costa ML

Broken bones (fractures) are a major cause of disability in adults. The time taken for a bone to heal (achieve "union") is an important factor in determining recovery after an injury. A minority of fractures fail to heal at all or in an appropriate period of time. This review set out to find out whether treatment with ultrasound, in a variety of forms, accelerates fracture healing and reduces complications associated with fresh (acute) fractures. A related intervention, shockwave therapy, was also examined. Typically, ultrasound treatment involves placing a special device in contact with the skin overlying the fracture site for around 20 minutes on a daily basis.

Twelve studies, involving 622 participants with 648 fractures, were included in this review. Most participants had suffered a fresh complete fracture of a single bone. The participants of two trials had incomplete or stress fractures, resulting from heavy exercise. Four trials tested the effects of ultrasound on healing of upper limb fractures and the other trials, on lower limb fractures. The most commonly investigated bone was the tibia (shin bone). Eleven trials tested low intensity pulsed ultrasound and one trial tested shockwave therapy.

Most trials compared a working ultrasound device with a sham device and thus protected against placebo effects. However, the results of many trials were probably biased because of missing data from several trial participants. Additionally, the trials were very varied; for example, in the bone that was broken and that some fractures were treated surgically. Based on analyses that adjusted for these missing data, the review found that the available evidence did not confirm that ultrasound speeded up bone healing or prevented non-union. The results from one low quality trial testing shockwave therapy were inconclusive. Few complications were reported and these were not related to the ultrasound or shockwave therapy.

Effectiveness and safety of first-line tenofovir + emtricitabine + efavirenz for patients with HIV

Omeje I;Okwundu CI — Wed, 15 Feb 2012 00:00:00 +0100

New

Omeje I, Okwundu CI

People living with HIV/AIDS and need to commence antiretroviral therapy (ART) should require a regimen that is convenient to administer, has good activity against the virus, few adverse effects (unwanted negative effects of the drug), and does not interact with other drugs. The regimen should also be affordable and readily available particularly in resource-poor settings.

This review identified one randomized controlled trial that compared the effects and safety of tenofovir + emtricitabine + efavirenz with another regimen for patients with HIV. The study showed that the regimen of tenofovir + emtricitabine + efavirenz proved superior particularly in terms of activity against the virus and also had fewer adverse events compared to a regimen of zidovudine + lamivudine + efavirenz. However, the findings of this single study cannot form the basis for the choice of tenofovir + emtricitabine + efavirenz as first-line regimen for patients with HIV. More randomized controlled trials are needed. Further trials should address issues of emergence of viral resistance and progression to AIDS.

Environmental sanitation measures to reduce trachoma transmission

Rabiu M;Alhassan MB;Ejere HOD;Evans JR — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Rabiu M, Alhassan MB, Ejere HOD, Evans JR

Trachoma is the commonest cause of preventable vision loss and is common in poor communities. Repeated bouts of conjunctivitis caused by chlamydia infection lead to scarring and turning in of the eyelid. The lashes rub the cornea causing opacification and blindness. Environmental sanitation is a package of measures aimed at eliminating factors that encourage proliferation of flies and the spread of the disease. Some of these interventions include provision of water and latrines as well insecticide spray to control flies and health education programmes to improve the personal and environmental hygienic practices of the people. We included six studies involving 12,294 participants of different ages and both sexes in this review. The trials were conducted in The Gambia, Mali, Tanzania, Niger and Ethiopia. Two studies looked at insecticide spray, one looked at insecticide spray and provision of latrines, one study looked at provision of latrines, and two studies looked at health education with one of them having health education combined with water supply. Prevalence of active trachoma, prevalence of Chlamydia trachomatis and fly count measures were the main outcomes assessed. Two studies conducted in the same area found insecticide spray effective in reducing active trachoma but one study in a different setting found the spray ineffective. A separate study found health education on personal and environmental hygiene to be effective in reducing active trachoma, however, another study found that a modest health education programme combined with a modest water supply was not effective in reducing active trachoma. One study on latrine provision found no impact on trachoma. However, more research is needed.

Evidence for the efficacy of piracetam for dementia or cognitive impairment is inadequate for clinical use but sufficient to justify further research

Flicker L;Grimley Evans J — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Flicker L, Grimley Evans J

Piracetam was one of the first drugs used for dementia and comes from the class of drugs called nootropics, whose putative actions are still poorly defined. Most of the trials of piracetam were undertaken many years ago and did not use methods which would be currently considered standard. Some of the studies suggested there may be some benefit from piracetam but overall the evidence is not consistent or positive enough to support its use for dementia or cognitive impairment.

Fluids and diuretics for treating acute ureteric colic

Worster AS;Bhanich Supapol W — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Worster AS, Bhanich Supapol W

Kidney stones are most commonly formed from masses of crystals and protein. Movement of stones from the kidney through the urinary tract is a common cause of urinary tract obstruction in adults and can cause severe pain (colic). This review aimed to determine if increased fluids and diuretics or both could hasten the passage of stones and improve symptoms. Neither our initial review nor this subsequent update identified sufficient evidence to enable conclusions to be determined about the safety and effectiveness of increasing fluids or diuretics or both to treat people with acute ureteric colic. More and larger randomised controlled studies are required.

Giving aminoglycoside antibiotics intravenously once daily compared to giving them several times per day in people with cystic fibrosis

Smyth AR;Bhatt J — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Smyth AR, Bhatt J

Cystic fibrosis is a serious genetic disorder which affects the lungs and the exocrine glands (sweat glands and others). Most people with cystic fibrosis develop persistent lung infections and they may receive frequent courses of intravenous antibiotics. Once-a-day doses reduce the cost and the time involved in giving the antibiotics, compared to several dose per day. This review includes four trials with a total of 328 people. All trials compared once-a-day dosing with three times-a-day dosing. The review found that giving the antibiotics once per day was just as good at treating lung infections in people with cystic fibrosis as the alternative treatment. The review found that giving the antibiotics once per day was just as good at treating lung infections in people with cystic fibrosis as the alternative treatment, though once daily appears less toxic to the kidneys in children. There were no differences between treatments for other outcomes. While once-daily treatment can be just as effective and more convenient than three-times daily treatment, we recommend further studies to look at the long-term safety of this treatment regimen.

Group parenting programmes for improving behavioural problems in children aged 3 to 12 years

Furlong M;McGilloway S;Bywater T;Hutchings J;Smith SM;Donnelly M — Wed, 15 Feb 2012 00:00:00 +0100

New

Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M

Parenting programmes that are delivered in group settings have the potential to help parents develop parenting skills that improve the behaviour of their young children. This review provides evidence that group-based parenting programmes improve childhood behaviour problems and the development of positive parenting skills in the short-term, whilst also reducing parental anxiety, stress and depression. Evidence for the longer-term effects of these programmes is unavailable. These group-based parenting programmes achieve good results at a cost of approximately $2500 (£1712 or €2217) per family. These costs are modest when compared with the long-term social, educational and legal costs associated with childhood conduct problems.

High pressure (hyperbaric) oxygen therapy for Bell's palsy

Holland NJ;Bernstein JM;Hamilton JW — Wed, 15 Feb 2012 00:00:00 +0100

New

Holland NJ, Bernstein JM, Hamilton JW

Bell's palsy is a weakness of one side of the face that is diagnosed after other causes of facial weakness have been ruled out. It is a 'diagnosis of exclusion'. Bell's palsy may be caused by a virus affecting the facial nerve. Standard treatment includes steroids to help settle swelling of the facial nerve, whereas antiviral treatment does not appear to help. In hyperbaric oxygen therapy, the person undergoing treatment breathes 100% oxygen in a pressurised chamber for about one hour (called a 'dive'). This may produce more dissolved oxygen in the facial nerve and might reduce nerve damage in Bell's palsy. We searched for evidence from randomised controlled trials on hyperbaric oxygen therapy in adults with moderate to severe Bell's palsy. Our searches revealed no trials that met the inclusion criteria for the review. We found very low quality evidence from one trial to suggest that hyperbaric oxygen therapy might be beneficial for moderate to severe Bell's palsy. The trial involved 79 participants and compared hyperbaric oxygen therapy to prednisone, a corticosteroid, which is a proven active treatment. The participants did not know which treatment they were being given. Those treated with hyperbaric oxygen recovered more quickly and recovered normal facial movement more often (95% versus 76%). All participants tolerated the treatment well, and there were no major complications. The quality of evidence from this trial was very low because the assessors of facial function were aware of which treatment each participant had been given, which introduces a high risk of bias. There is therefore no high quality evidence on which to base conclusions about the efficacy of hyperbaric oxygen therapy in Bell's palsy.

Hydrocolloid dressings to promote foot ulcer healing in people with diabetes when compared with other dressing types

Dumville JC;Deshpande S;O'Meara S;Speak K — Wed, 15 Feb 2012 00:00:00 +0100

New

Dumville JC, Deshpande S, O'Meara S, Speak K

Diabetes, a condition which leads to high blood glucose concentrations, is a common condition with around 2.8 million people affected in the UK (approximately 4.3% of the population). Dressings are commonly used to treat foot ulcers in people with diabetes. There are many types of dressings that can be used, which also vary considerably in cost.This review (four studies involving a total of 511 participants) identified no research evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing.

Inconclusive, but promising evidence for the efficacy of functional analysis interventions for challenging behaviour in dementia

Moniz Cook ED;Swift K;James I;Malouf R;De Vugt M;Verhey F — Wed, 15 Feb 2012 00:00:00 +0100

New

Moniz Cook ED, Swift K, James I, Malouf R, De Vugt M, Verhey F

The management of challenging behaviour, such as aggression and agitation in dementia has been dominated by drug therapies such as the antipsychotics, despite their modest efficacy, side effects and potential detriment to quality of life. Functional analysis (FA) is a behavioural intervention that is described by international guidelines as the first line alternative to drug therapy for challenging behaviour. FA typically requires the therapist to develop an understanding of the function or meaning behind the person’s distressed behaviour. It uses this understanding to develop individually tailored strategies aimed at both the person with dementia and the caregivers, to relieve the distress caused by the behaviour. FA can be applied in home settings where the family or informal caregiver is offered support from a therapist, or in care homes, hospitals or assisted living settings, where training in FA and specialist support to deliver interventions is provided for staff.

In this review we analysed the effectiveness of functional analysis-based interventions for challenging behaviour in dementia. We found eighteen randomised controlled trials suitable for analysis in all four types of care settings. The majority were in family care settings and there were surprisingly few care home based studies. Most evaluated broad programmes of care, where FA was just one component of a wide range of other interventions. This made it hard to determine the real effect of FA for the management of challenging behaviour in dementia.

However, positive results were noted in the frequency of the person’s reported problem behaviours and the caregiver’s reaction to them. No significant effects were found for incidence or severity of mood and other problem behaviours. Similarly, no significant effects were found for caregiver mood or burden.

Whilst it is too early to reach a firm conclusion on the evidence for FA in the management of challenging behaviour in dementia, we note emerging beneficial effects on challenging behaviour where multi-component psychosocial interventions have used FA as part of the programme of care.

Injections of bulking agents for urinary incontinence in women

Kirchin V;Page T;Keegan PE;Atiemo K;Cody JD;McClinton S — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton S

Stress incontinence is losing urine when coughing, laughing, sneezing or exercising. Usually muscles and tissue form a cushion supporting the base of the bladder and closing the urethra (the passage through which urine leaves the body). If they do not, artificial cushioning can be created by injecting bulking agents into the area around the urethra. The review of 14 trials, which included 2004 women, found some limited evidence that this can relieve stress incontinence in women. Other treatments such as surgery might be better. Using the women's own fat tissue as the agent injected can cause serious complications.

Interventions for atrophic rhinitis

Mishra A;Kawatra R;Gola M — Wed, 15 Feb 2012 00:00:00 +0100

New

Mishra A, Kawatra R, Gola M

Atrophic rhinitis is a chronic nasal condition with unknown cause. It is characterised by the formation of thick dry crusts in a roomy nasal cavity, which has resulted from progressive wasting away or decrease in size (atrophy) of the mucous nasal lining (mucosa) and underlying bone. The various symptoms include foetor (strong offensive smell), crusting/nasal obstruction, nosebleeds, anosmia (loss of smell) or cacosmia (hallucination of disagreeable odour), secondary infection, maggot infestation, nasal deformity, pharyngitis, otitis media and even, rarely, extension into the brain and its membranes. Atrophic rhinitis can be classed as primary or, where it is a consequence of another condition or event, secondary. Its prevalence varies in different regions of the world but it is common in tropical countries. A wide variety of treatments have been described in the literature, however treatment is usually conservative (for example, nasal irrigation and douches; nose drops (e.g. glucose-glycerine, liquid paraffin); antibiotics and antimicrobials; vasodilators (drugs that cause dilation of blood vessels) and prostheses). Surgical treatment aims to decrease the size of the nasal cavities, promote regeneration of normal mucosa, increase lubrication of dry nasal mucosa and improve the vascularity (blood flow) of the nasal cavities.

We searched systematically for randomised controlled trials (RCTs) studying any treatment or combination of treatments for atrophic rhinitis in patients with atrophic rhinitis. Despite a comprehensive search we found no RCTs which met our inclusion criteria, although a RCT comparing surgery (Young’s operation) with nasal lubrication for primary atropic rhinitis is underway. Further high-quality research into this chronic disease, with a longer follow-up period, is therefore required to conclusively establish the long-term benefits or risks of different treatment modalities for atrophic rhinitis.

Interventions for drooling in children with cerebral palsy

Walshe M;Smith M;Pennington L — Wed, 15 Feb 2012 00:00:00 +0100

New

Walshe M, Smith M, Pennington L

Many children with CP have difficulty controlling saliva. Drooling varies in severity and can be distressing for the children, families and caregivers. Excessive drooling can cause constant damp soiled clothing, unpleasant odour, irritated, chapped or sore skin around the mouth and chin, skin and mouth infections, dehydration, difficulties chewing, interference with speech, damage to books, communication aids, computer and audio equipment. There is also risk of social rejection and social isolation for these children.

Many interventions are used to reduce or eliminate drooling. These include surgery, medications, botulinum toxin (BoNT-A and BoNT-B)), physical therapies, therapies to improve sensory function, behavioural therapies to assist the child in managing his/her own drooling, appliances placed in the mouth, and acupuncture.

There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. This makes it hard to decide which intervention will be safest and most effective.

Only RCTs and CCTs were included in this review. Trials were identified by electronic searches of databases, searches of clinical trials registers, peer reviewed journals, published conference proceedings and reference lists of relevant articles.

Six trials were found. Four examined the safety and efficacy of BoNT-A and two examined benztropine and glycopyrrolate. No trials were found on other interventions. The quality of trials was variable. The trials all differed in the children recruited, the product used, how the product was delivered and how its effectiveness was measured. All trials reported a positive reduction in drooling and all showed some statistically significant change for treatment groups up to 1 month post intervention. Few studies examined client and/or carer satisfaction with the intervention. Some looked at side effects of the intervention but no study examined the effect of interventions on the child's quality of life or psychological well being.

There is insufficient evidence to support the use of one intervention over another. As trials on just two kinds of interventions were retrieved, and given the variation and quality of these studies, it is not possible to conclude that one intervention is more effective than another. The lack of trials on other interventions does not suggest that these interventions are ineffective.

Adequately powered well designed trials are required across all interventions. In addition to using sensitive measures looking at change in salivary flow, measures are needed that examine client and carer satisfaction, changes in quality of life, psychological well being and in unwanted symptoms associated with drooling.

Interventions for prevention of giant retinal tear in the fellow eye

Ang GS;Townend J;Lois N — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Ang GS, Townend J, Lois N

A giant retinal tear is a full-thickness retinal break that extends for 90 degrees or more around the circumference of the retina, in the presence of posterior vitreous detachment (when the vitreous comes away from the retina). Giant retinal tears cause visual loss as a result of the associated retinal detachment. They can be difficult to treat due to the large area of retinal involvement and the high risk of re-detachment following vitreoretinal surgery, often related to the development of proliferative vitreoretinopathy (a scarring process that can happen on the inner or outer surface of the retina and in the vitreous cavity after retinal detachment). As the fellow eye has an increased risk of developing giant retinal tear and retinal detachment, prophylactic 360-degree treatments with laser photocoagulation, cryotherapy or encircling scleral buckling have been proposed to reduce this risk. This review did not find any strong evidence in the form of prospective randomised controlled trials or case-control studies to support or refute these prophylactic treatments.

Interventions for replacing missing teeth: management of soft tissues for dental implants

Esposito M;Maghaireh H;Grusovin MG;Ziounas I;Worthington HV — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthington HV

Dental implants are usually placed by elevating a soft tissue flap, but in some instances, they can also be placed without flap elevation to reduce postoperative discomfort. Several flap and suturing techniques have been proposed. Soft tissues are often manipulated and augmented for aesthetic reasons. It is often recommended that implants are surrounded by 'firm' (attached/keratinised) soft tissues rather than 'movable' gums to improve their long-term prognosis.
The review found some weak evidence from only two studies with 56 patients that flapless placement of dental implants reduces postoperative discomfort (pain and swelling), without jeopardising implant success in selected patients. There is insufficient evidence to recommend any specific flap or suturing technique. There is only a small study (10 patients) suggesting that soft tissue grafts from the palate improve gum thickness and aesthetics. There are no studies evaluating whether there is a benefit in increasing the amount of firm gum surrounding dental implants but there is a small trial suggesting that it is possible to increase the amount of firm gum surrounding dental implants using either tissue taken from the palate or a porcine-derived collagen matrix at the price of considerable postoperative pain/discomfort and aesthetic deterioration (there were several cases where the gum receded exposing the metal of the implant).

Interventions for replacing missing teeth: partially absent dentition

Abt E;Carr AB;Worthington HV — Wed, 15 Feb 2012 00:00:00 +0100

New

Abt E, Carr AB, Worthington HV

Methods for treating patients with some missing teeth.

Patients with some missing teeth have several treatment options available to them. They need to know what the treatment options are, how much they cost and how long they can be expected to last. This review compares the options available which includes combinations of fixed and removable dentures, bridges and implants. Although there were 21 trials included in this review, there were so many variations in the types of these interventions that it is not possible to determine which are effective replacements for missing teeth in terms of durability, function, comfort and appearance. The trials also failed to report comparisons between the costs of different treatments or any possible harms.

Interventions for treating placental abruption

Neilson JP — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Neilson JP

There is no evidence from trials to show the best way to help pregnant women and babies when there is a placental abruption.

The placenta is attached to the baby by the umbilical cord, and to the inside of the uterus. If the placenta starts separating from the uterus before the baby is born, it is called placental abruption. It can be caused by a medical problem or physical trauma. This quickly becomes life-threatening for women and babies, and cannot be repaired. The baby may need to be delivered immediately, by caesarean section if alive, and often vaginally if the baby has died. Additional treatments include pain relief, blood transfusion and monitoring. However, the review found no trials to show which treatments are best.

Intramuscular versus intravenous oxytocin for reducing blood loss after vaginal birth

Oladapo OT;Okusanya BO;Abalos E — Wed, 15 Feb 2012 00:00:00 +0100

New

Oladapo OT, Okusanya BO, Abalos E

Oxytocin given to a woman during or immediately after the birth of her baby (prophylactically) is effective in reducing excessive bleeding after vaginal birth. There is no reliable research to show whether giving the oxytocin into a muscle or vein makes any difference to the effectiveness of the oxytocin or the health of the mother and baby.

The third stage of labour is the period between the birth of the baby and the delivery of the placenta. Excessive blood loss during this period or immediately thereafter can be prevented by giving oxytocin, which is a drug that makes the womb contract to close the blood vessels in the placenta and helps it separate from the wall of the uterus. When injected into a vein, oxytocin starts to work almost immediately whereas it takes some three to seven minutes when injected into a muscle. Oxytocin given into a vein has been reported to occasionally cause serious side effects such as a sudden drop in blood pressure and an increase in heart rate, particularly when given rapidly in a small amount of solution (undiluted). The method involved in injecting oxytocin into a muscle takes much less time than those involved for injecting it into a vein. It is also more convenient for the provider, requires relatively less skill and thus can be given by providers with limited skills. This review found no randomised controlled trials to show whether giving oxytocin into a muscle or vein is better than the other in terms of potential benefits, side effects or risks to the mother or the baby.

Lacosamide for neuropathic pain and fibromyalgia in adults

Hearn L;Derry S;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Hearn L, Derry S, Moore RA

Antiepileptic drugs like lacosamide are commonly used for treating neuropathic pain, usually defined as pain due to damage to nerves. This would include postherpetic neuralgia (persistent pain experienced in an area previously affected by shingles), painful diabetic neuropathy, nerve injury pain, phantom limb pain and trigeminal neuralgia; fibromyalgia also responds to some antiepileptic drugs. This type of pain can be severe and long-lasting, is associated with lack of sleep, fatigue, depression and a reduced quality of life. This review included five studies in painful diabetic neuropathy (1863 participants) and one in fibromyalgia (159 participants). In people with painful diabetic neuropathy, lacosamide had only a modest effect, with a specific effect due to its use in 1 person in 10. This is a minor effect and may be an over-estimate due to use of the last observation carried forward method for analysis. There was insufficient information in fibromyalgia to draw any conclusions about the effect of lacosamide. There was no significant difference between lacosamide and placebo for participants with any, or a serious, adverse event, but there were significantly more adverse event withdrawals with lacosamide. Regulatory authorities have not licensed lacosamide for treating pain based on evidence presently available.

Laser peripheral iridoplasty for angle-closure glaucoma

Ng WS;Ang GS;Azuara-Blanco A — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Ng WS, Ang GS, Azuara-Blanco A

Glaucoma is a leading cause of irreversible blindness in the world. Angle-closure glaucoma describes one of the mechanisms which leads to glaucoma. In angle-closure, the "angles" that act as drains for the aqueous in the eye are closed which leads to high eye ball pressure. Treatment is aimed at opening the drainage system and lowering the pressure in the eye with medical or surgical treatment or both. Laser peripheral iridoplasty is used in patients with angle-closure when other treatments fail to open the anterior drainage system. It works by shrinking and pulling the peripheral iris tissue away from the trabecular meshwork (angles). Although one randomised controlled trial with 158 participants was found, due to its limitations and the lack of a statistically significant difference observed with laser peripheral iridoplasty intervention, this review found no strong evidence for the use of laser peripheral iridoplasty in the treatment of angle-closure in the non-acute setting.

Massage, reflexology and other manual methods for managing pain in labour

Smith CA;Levett KM;Collins CT;Jones L — Wed, 15 Feb 2012 00:00:00 +0100

New

Smith CA, Levett KM, Collins CT, Jones L

The pain of labour can be intense, with tension, anxiety and fear making it worse. Many women would like to labour without using drugs such as narcotics or epidurals, and turn to complementary therapies to help them manage the pain of labour. Many complementary therapies are tried and in this review we have looked to see if massage, reflexology and other manual healing methods are effective. Other complementary therapies like acupuncture, mind-body techniques, hypnosis and aromatherapy have been studied in other reviews. Massage involves manipulating the body’s soft tissues and it can be done by the midwife or partner. It helps women relax and so reduces the tension which increases pain in labour. Reflexology is gentle manipulation or pressing on certain parts of the foot to produce an effect elsewhere in the body. Other manual healing methods include osteopathy, shiatsu and zero balancing etc.

We found six studies, with data available from five trials on 326 women, looking at the use of massage in labour for managing pain. There were no studies on any of the other manual healing methods. The six studies were of reasonable quality but more participants are needed to provide robust information. We found that women who used massage felt less pain during labour when compared with women given usual care during first stage. However, more research is needed.

Medical interventions for fungal infection of the clear front part of the eye (cornea)

FlorCruz NV;Peczon IV;Evans JR — Wed, 15 Feb 2012 00:00:00 +0100

Updated

FlorCruz NV, Peczon IV, Evans JR

Fungal keratitis (fungal infection of the cornea) occurs rarely in higher income countries but is relatively common in lower income countries. If left untreated the cornea may perforate and may lead to blindness. Although there are a number of medications available, it is not clear which is the most effective and cost-effective. This review identified nine randomised controlled trials with 568 participants using different combinations of antifungal drugs. The trials were mainly conducted in India; they were small and of variable quality. Although there were some observed differences, these could have occurred by chance; none of the studies were large enough to determine conclusively which agents work best. Further trials with a larger sample size are required in order to answer this important question.

Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma

Narayanan K;Hadid OH;Barnes EA — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Narayanan K, Hadid OH, Barnes EA

A basal cell carcinoma (BCC) is the commonest skin cancer and the most common cancer in people of white origin. It is usually seen on the sun exposed parts of the body like the face, neck, head and ears. Untreated lesions can slowly eat away the surrounding skin and hence they are also called "rodent ulcers". The commonest treatment for BCC is surgery. This is traditionally achieved by surgical excision (SE) which involves cutting away the BCC, along with a margin of normal appearing skin around it to ensure complete removal of the cancer and to reduce the risk of recurrence. Another type of surgery is Mohs micrographic surgery (MMS). This involves the removal of the skin tumour after colour coding the edges. This is then examined under the microscope to see if all the BCC has been removed. If any residual BCC is left at the edge of the excision further skin is excised from only that localised area by using the colour coding, and examined under the microscope. This process is continued until all the BCC is removed. This ensures complete tumour removal and spares normal tissue in the other directions. The latter is considered the better alternative for treatment of certain types of BCC arising in the eyelids because it has the highest chance of curing the disease and minimises the size of the defect that needs to be repaired. Unfortunately, this modality of therapy is a limited resource and not always employed because of practical limitations in the service delivery. Surgical excision is perceived to be a cheaper option as it does not require the special training, multiple procedures, and money involved in setting up and running a MMS service. Extended follow up, greater surgical morbidity and the cost of dealing with recurrences may over time significantly increase the cost of SE. We searched for studies where people with BCC had been randomised to receive either method of treatment. The aim was to establish which treatment method is associated with lower recurrence rate. We also looked at the cost difference, complications and acceptability of the two procedures. This review could not find enough evidence to answer these questions. There is a clear need for further randomised studies to provide more reliable evidence for the management of this condition.

Non surgical therapy for anal fissure.

Nelson RL;Thomas K;Morgan J;Jones A — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Nelson RL, Thomas K, Morgan J, Jones A

Anal fissure is a painful ulcer usually occurring in the posterior midline of the skin just outside the entry to the rectum. Its persistence is due to spasm of the internal sphincter muscle. The typical pain of this condition is pain on moving one's bowels that persists for some time afterward. Relief with healing of chronic fissures until very recently has been achieved by surgical procedures aimed at ablation of the sphincter spasm. Because of the risk of incontinence resulting from surgery, medical alternatives for surgery have been sought. Among the older medications, bran is effective in preventing recurrence of acute fissure. Local application of muscle relaxing therapy is effective in healing chronic anal fissure, though not as well as surgery, and with considerable risk of adverse events during therapy. There is a Cochrane review related to this review dealing only with surgical procedures.

Non-steroidal anti-inflammatory drugs for treating fluid accumulation in the macula after cataract surgery

Sivaprasad S;Bunce C;Crosby-Nwaobi R — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Sivaprasad S, Bunce C, Crosby-Nwaobi R

Cystoid macular oedema (CMO) is the accumulation of fluid in the macula (central retina) due to leakage from capillaries. Clinically significant CMO following cataract surgery is a complication of unknown cause. Acute CMO, defined as oedema of less than four months duration, often gets better spontaneously. This review included seven randomised controlled trials with a total of 266 participants. Four trials studied the effects of non-steroidal anti-inflammatory agents (NSAIDs) in chronic CMO while the other three examined the effect of NSAIDs in acute CMO. This review found two trials which showed that topical NSAID (0.5% ketorolac tromethamine ophthalmic solution) has a positive effect on chronic CMO and a third trial which was supportive of this finding (albeit not statistically significantly so). One study suggested no effect and our review suggests further work is needed for a more conclusive decision regarding use of NSAIDS in chronic CMO. Similarly, the effects of NSAIDs in acute CMO remain unclear and this too needs further investigation.

Oral antihistamine-decongestant-analgesic combinations for the common cold

De Sutter AIM;van Driel ML;Kumar AA;Lesslar O;Skrt A — Wed, 15 Feb 2012 00:00:00 +0100

New

De Sutter AIM, van Driel ML, Kumar AA, Lesslar O, Skrt A

The common cold is probably the most common illness known and usually presents with a range of symptoms such as sore throat, nasal stuffiness and discharge, sneezing and cough. On average, young children have six to eight colds per year and adults have two to four. It is caused by viruses (more than 200 viruses have been implicated) and is generally not a serious condition which usually resolves by itself within one to two weeks. However, the common cold has a large impact on time lost from work or school and causes substantial discomfort.

As there is no cure for the common cold, only symptomatic treatment is available. Many people use oral over-the-counter (OTC) medications that contain antihistamines, decongestants, analgesics or a combination to self treat the symptoms of the common cold. Our review of 27 trials with over 5000 participants shows some benefit of these treatments in adults and older children with regards to general recovery and symptoms. The combination of antihistamine-decongestant is the most effective combination but many people experience adverse effects such as drowsiness, dry mouth, insomnia and dizziness. There is no evidence for a beneficial effect in young children. The included trials studied very different populations, treatments and outcomes but overall the methodological quality was acceptable.

Over-the-counter medications to help reduce cough for children and adults on antibiotics for acute pneumonia

Chang CC;Cheng AC;Chang AB — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Chang CC, Cheng AC, Chang AB

There are many causes of acute cough, one of which is pneumonia. Cough is burdensome and impairs quality of life. To ameliorate cough, over-the-counter (OTC) medications are commonly used by patients and recommended by healthcare staff as adjuncts in the treatment of pneumonia. There are many classes of OTCs for cough, such as mucolytics (medications that can reduce the thickness of mucus) and antitussives (medications that suppresses cough).

In this review we found four studies with a total of 224 participants that were suitable for inclusion; one was performed exclusively in children and three in adolescents or adults. However, data could only be obtained from two studies; both studies used mucolytics (ambroxol and bromhexine) in conjunction with antibiotics. Combining these two studies, the rate of cure or improvement in cough of people who received mucolytics was similar to those who did not. However, in the secondary analysis, children who received a mucolytic were more likely to be cured of cough (number needed to treat to benefit (NNTB) at day 10 was 5 (95% CI 3 to 16) for children and 4 (95% CI 3 to 8) for adults). There were no reported increased adverse events in the treatment group.

The range of possible adverse events in OTCs for cough is wide and includes minimal adverse events (such as use of honey) to serious adverse events such as altered heart rate patterns, drowsiness and death in young children. The studies included in this review did not report any detectable increase in adverse events.

The review has substantial limitations due to the unavailability of data from studies. Also there are no studies that have used other common OTCs used for cough, such as antihistamines and antitussives.

Thus, there is insufficient evidence to draw any conclusions about whether OTC medications taken as an adjunctive treatment for cough associated with acute pneumonia are beneficial or not. Mucolytics may be beneficial but the lack of consistent evidence precludes recommending the routine use of mucolytics as an adjunct in the treatment of troublesome cough associated with pneumonia in children or adults.

Palivizumab vaccine for prevention of respiratory syncytial virus infection in children with cystic fibrosis

Robinson KA;Odelola OA;Saldanha IJ;Mckoy NA — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Robinson KA, Odelola OA, Saldanha IJ, Mckoy NA

Respiratory syncytial virus is a virus which commonly causes lung infections in infants and children. Although cases in most children are not severe, children with cystic fibrosis may be at higher risk for severe respiratory syncytial virus lung infections. Children with cystic fibrosis are more likely to require hospitalisation and experience deterioration in lung function during a respiratory virus season, compared with children without cystic fibrosis. Palivizumab (Synagis®) is a vaccine which has been shown to reduce hospitalisation rates due to respiratory syncytial virus in some high risk populations. Its effectiveness and safety in children with cystic fibrosis has not been established. We looked for randomised controlled trials comparing the use of palivizumab preventive therapy to either other preventive therapy or no preventive therapy in children with cystic fibrosis. We found one study with 186 participants (infants with cystic fibrosis up to two years of age). One infant (from 92) who received palivizumab and one infant (from 94) who received placebo were hospitalised due to respiratory syncytial virus infection. No infants died. Overall, the number of adverse events in the palivizumab group was similar to that in the placebo group. No serious adverse events were reported to be related to the vaccine. Over the longer term (12 months), weight gain and number of infections with Pseudomonas aeruginosa (a common bacterial infection in cystic fibrosis) were similar between groups. The limitation of all these findings is that this was the only study we identified. More research is needed on the use of palivizumab prophylaxis in children with cystic fibrosis.

Paying for performance to improve the delivery of health interventions in low- and middle-income countries

Witter S;Fretheim A;Kessy FL;Lindahl AK — Wed, 15 Feb 2012 00:00:00 +0100

New

Witter S, Fretheim A, Kessy FL, Lindahl AK

Researchers in the Cochrane Collaboration conducted a review of the effect of paying for performance to improve the delivery of health care in low- and middle-income countries. After searching for all relevant studies, they found nine studies that met their requirements. The findings of this review are summarised below.

What is pay for performance?

In a 'pay for performance' approach, people are given money or other rewards if they carry out a particular task or hit a particular target. This approach can be directed at patients, health workers or healthcare organisations. Patients are sometimes rewarded if they use particular healthcare services. Health workers and healthcare organisations may be rewarded if they offer particular services, if they deliver care that is of a certain quality, or if their patients make use of particular services. This review focused on pay for performance approaches that target the behaviour of health workers and healthcare organisations.

What happens when health workers and healthcare organisations are paid for performance?

The quality of the evidence was generally very low. The pay for performance approaches used in each study varied a great deal and the studies were carried out in a wide range of settings. It is therefore not possible to draw general conclusions. There is a need for more and better research in this area.

Pentoxifylline for diabetic kidney disease

Shan D;Wu HM;Yuan QY;Li J;Zhou RL;Liu GJ — Wed, 15 Feb 2012 00:00:00 +0100

New

Shan D, Wu HM, Yuan QY, Li J, Zhou RL, Liu GJ

Kidney disease develops in 25% to 40% of diabetic patients, usually 20 to 25 years after the onset of diabetes. Approximately one third of those with diabetic kidney disease (DKD) will progress to end-stage kidney disease (ESKD) and will require long-term dialysis or possibly receive a kidney transplant. Many patients however may die from associated coronary artery disease or other cardiovascular causes before the onset of ESKD. Pentoxifylline has been described as offering properties that may be beneficial for patients with DKD. We reviewed 17 randomised controlled studies, enrolling 991 patients with DKD, which compared pentoxifylline with placebo, routine treatment or antihypertensive drugs.

Compared with placebo, pentoxifylline significantly reduced serum creatinine (SCr), albuminuria, and overt proteinuria, but not creatinine clearance (CrCl). When compared with routine treatment alone, pentoxifylline did not reduce SCr or blood pressure, but did significantly reduce albuminuria and proteinuria. Compared to captopril or clonidine/methyldopa there was no significant difference in SCr, albuminuria, proteinuria or blood pressure for patients with type 1 and type 2 DKD. CrCl was significantly increased when pentoxifylline was compared to clonidine/methyldopa but not with captopril. No data were available on the incidence of ESKD, time to ESKD, quality of life, or all-cause mortality. The adverse events of pentoxifylline were mild; no serious adverse events were reported in any of the included studies.

Pentoxifylline seemed to have some beneficial effects in improving kidney function and reducing albuminuria and proteinuria (which can indicate kidney health) for patients with DKD, and was not associated with any major adverse effects. However, the current evidence on the effects of pentoxifylline for patients with DKD was insufficient to formulate therapeutic recommendations. More large, high-quality randomised studies are needed to better inform clinical decision making about the use pentoxifylline for patients with DKD.

Physiotherapy for treatment of Parkinson's disease

Wed, 15 Feb 2012 00:00:00 +0100

Updated

Tomlinson CL, Patel S, Meek C, Clarke CE, Stowe R, Shah L, Sackley C, Deane KHO, Wheatley K, Ives N

In spite of various medical and surgical treatments for Parkinson's disease (PD), patients gradually develop significant physical problems. Physiotherapists aim to enable people with PD to maintain their maximum level of mobility, activity and independence through monitoring their condition and targeting the appropriate treatment. A range of approaches to movement rehabilitation are used, which aim to enhance quality of life by maximising physical ability and minimising secondary complications over the whole course of the disease.

Only randomised controlled trials were included in this review. These were studies where a group of participants were given physiotherapy intervention and compared with another group who did not receive physiotherapy. The participants were assigned to a group in a random fashion to reduce the potential for bias. Thirty-three randomised trials involving 1518 participants were identified as suitable for this review. The trials assessed various physiotherapy interventions, so the trials were grouped according to the type of intervention being used (general physiotherapy, exercise, treadmill training, cueing, dance or martial arts).

There was an improvement with physiotherapy intervention in all walking outcomes (except the 10- or 20-metre walk test). However, these improvements were only significant for walking speed, walking endurance and step length. Mobility and balance outcomes were also improved with physiotherapy intervention, with significant improvements in one test of mobility (the Timed Up & Go test which times how long it takes a person to get up from a chair, walk a certain distance, then walk back to the chair and sit down) and in two tests of balance (one assessing how far a person can reach before they lose balance (Functional Reach Test) and another which assesses multiple aspects of balance (Berg Balance Scale)). Clinician-rated disability, using the Unified Parkinson’s Disease Rating Scale (UPDRS), was also improved with physiotherapy intervention. There was no difference between the two groups in data on falls or patient-rated quality of life. When comparing the different physiotherapy interventions, there was no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed.

This review provides evidence on the short-term benefit of physiotherapy for the treatment of PD. Although most of the observed differences were small, the improvements seen for walking speed, balance with the Berg Balance Scale and clinician-rated disability (using the UPDRS) were of a size that patients would consider an important improvement.

Pneumococcal vaccines for sickle cell disease

Davies EG;Hirst C;Lottenberg R;Dower N — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Davies EG, Hirst C, Lottenberg R, Dower N

People with sickle cell disease are particularly prone to pneumococcal infection, which may be fatal. Children aged up to 23 months are at high risk, but usual polysaccharide pneumococcal vaccines may not work in this age group. New conjugate pneumococcal vaccines may help to reduce the rate of infection in people with sickle cell disease of all ages. We searched for trials which compared a polysaccharide or conjugate pneumococcal vaccine schedule with a different schedule or no vaccination in people with sickle cell disease. The review includes five trials with a total of 547 participants. One trial showed that the polysaccharide vaccine did not reduce the risk of infection very much in children younger than three years old, but it was linked with only minor adverse events. Three trials of conjugate vaccines showed increased antibody responses compared to control groups in people of all ages, although clinical outcomes were not measured in these trials. This review did not show if the vaccines prevent infection or decrease death rates. We recommend that conjugate pneumococcal vaccines are used in people with sickle cell disease. Randomised trials will be needed to determine the best vaccination schedule when further, potentially more effective vaccines become available. Such trials should measure clinical outcomes of effectiveness.

Protective treatment against blood clots in non-hospitalised cancer patients receiving chemotherapy

Di Nisio M;Porreca E;Ferrante N;Otten H-M;Cuccurullo F;Rutjes AWS — Wed, 15 Feb 2012 00:00:00 +0100

New

Di Nisio M, Porreca E, Ferrante N, Otten H-M, Cuccurullo F, Rutjes AWS

Cancer patients are more likely than patients without cancer to develop blood clots in their veins (venous thromboembolism), either in the lungs (pulmonary embolism) or the deep venous system (deep vein thrombosis or DVT). Chemotherapy further increases this risk. Yet bleeding at the site of the cancer and a relative decrease in number of platelets in the blood (thrombocytopenia) caused by the chemotherapy may make cancer patients more likely to have bleeding complications with blood thinning agents. This systematic review looked at the effectiveness and safety of blood thinning agents (anticoagulants) when used to prevent blood clots in cancer patients receiving chemotherapy. Nine randomised controlled studies with a total of 3538 patients investigated the prevention of blood clots in patients without a history of blood clots. The use of low molecular weight heparin was associated with a reduction in blood clots (the number needed-to-treat to prevent a symptomatic blood clot was 60) without any clear benefit in survival as the number of major bleeding events was increased, although this was not statistically significant and further study is needed. The findings from two studies of the vitamin K antagonist warfarin, one comparing warfarin with low molecular weight heparin in patients with myeloma, were too limited to support a beneficial effect of warfarin in the prevention of blood clots in cancer patients. Antithrombin was evaluated in one study in children and had no significant effect on blood clots or major bleeding when compared with an inactive control.

Overall the studies had a low risk of bias but the small number of studies, participants and clinical events prevented the review authors from making definite conclusions on the effectiveness of these medications. For the same reasons, we could not determine if the treatment effect differed with age (below 65 years or above 65 years), type of cancer or stage of cancer (metastatic versus non metastatic). None of the studies tested other anticoagulant treatment including unfractionated heparin, fondaparinux, direct factor Xa inhibitors or mechanical interventions (intermittent pneumatic compression and graduated elastic stockings).

Psychological therapies for sickle cell disease and pain

Anie KA;Green J — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Anie KA, Green J

Sickle cell disease is a group of blood disorders. It can cause anaemia, which if severe can reduce mobility. It may also allow small blood vessels to become blocked causing pain in muscle and bone and it can damage major organs such as the spleen, liver, kidneys, and lungs. People with sickle cell disease are more vulnerable to severe infections. Treatment is usually in response to symptoms and designed to ease pain. Psychological treatment to help people cope with sickle cell disease might complement current medical treatment. There are four types of treatment: patient education; cognitive therapy (to do with thoughts and feelings); behavioural therapy (to do with actions); psychodynamic psychotherapy (talking to relieve emotional pain). We searched for randomised or quasi-randomised controlled trials which compared psychological treatments to each other or to no treatment in sickle cell disease. We included six studies in the review. Four studies with 223 people had data we could enter in the review. One study showed that cognitive behaviour therapy reduced the affective part of pain, but not the sensory part. Another study of this therapy had inconclusive results for coping strategies and showed no difference on how different groups used the health service. One education study did not show a reduction in depression. The authors believe that some patient education seems relevant for children and adolescents, while methods to improve the ability to cope in both children and adults are important. However, more research needs to be done in this area.

Robotic surgery for benign gynaecological disease

Liu H;Lu D;Wang L;Shi G;Song H;Clarke J — Wed, 15 Feb 2012 00:00:00 +0100

New

Liu H, Lu D, Wang L, Shi G, Song H, Clarke J

In recent years, robotic surgery or robot-assisted surgery has been developed to support a range of surgical procedures. Robotic surgery in benign gynaecological disease is one of the fastest growing areas, for conditions such as removal of the uterus or uterine fibroids, reuniting a divided tube, and to cure vaginal vault prolapse. Robotic surgery may lead to reduced blood loss, favourable complication rates, and short hospital stays. However, this systematic review found only limited evidence that refutes the previous points of view and does not support the use of robotic surgery for women with benign gynaecological disease.

Saline irrigation for the management of skin extravasation injury in neonates

Gopalakrishnan PN;Goel N;Banerjee S — Wed, 15 Feb 2012 00:00:00 +0100

New

Gopalakrishnan PN, Goel N, Banerjee S

Preterm and sick term infants requiring intravenous fluids and medications are vulnerable to tissue injury secondary to extravasation that is, leakage of fluid into the surrounding tissue. Such injury can result in scarring with consequent cosmetic issues and, in some infants, functional limitation. Remedial surgical intervention may be required for some babies. Saline flush out, with or without prior infiltration of hyaluronidase (a protein that helps the breakdown of barriers that hold tissue planes together), is widely used in the management of severe extravasation injury in neonates and aims to prevent or reduce complications following the extravasation. Conservative treatment with normal wound care and various topical dressings is commonly used. We planned to examine if saline flush out with or without prior hyaluronidase infiltration into the injured area resulted in better short and long-term cosmetic and functional outcomes when compared to normal wound care. We did not find any study that currently answers this question.

Somatostatin analogues for acute bleeding oesophageal varices

Gøtzsche PC;Hróbjartsson A — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Gøtzsche PC, Hróbjartsson A

Cirrhosis of the liver is a chronic, progressing disease that is most commonly caused by excessive use of alcohol or by hepatitis C infection. The liver tissue is replaced by connective tissue, which leads to loss of liver function. People with cirrhosis of the liver may develop varicose veins (enlarged blood vessels or varices) in the gullet. Bleeding varices can be life-threatening. The hormone somatostatin, or similar drugs like octreotide and vapreotide, can be used to try to stop the bleeding. The review of 21 trials (2588 patients) found that the tested drugs did not reduce deaths. There was a small reduction in the need for blood transfusions, corresponding to one half unit of blood saved per patient. It is doubtful whether this effect is worthwhile.

Speech and language therapy for speech problems in Parkinson's disease

Herd CP;Tomlinson CL;Deane KHO;Brady MC;Smith CH;Sackley C;Clarke CE — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Herd CP, Tomlinson CL, Deane KHO, Brady MC, Smith CH, Sackley C, Clarke CE

Many people with Parkinson's disease suffer from disorders of speech. The most frequently reported speech problems are weak, hoarse, nasal or monotonous voice, imprecise articulation, slow or fast speech, difficulty starting speech, impaired stress or rhythm, stuttering and tremor. People with the condition also tend to give fewer non-verbal cues, such as facial expressions and hand gestures. These disabilities tend to increase as the disease progresses and can lead to serious problems with communication.

This review compared the benefits of speech and language therapy versus placebo (sham therapy) or no treatment for speech disorders in Parkinson's disease. Relevant trials were identified by electronic searches of 16 medical literature databases, various registers of clinical trials and an examination of the reference lists of identified studies and other reviews.

Only randomised controlled trials were included in this review. These were studies where two groups of patients were compared, one group had speech and language therapy, the other did not receive any therapy intended to improve speech. The patients were assigned to each of the groups in a random fashion so as to reduce the potential for bias.

Three trials with a total of 63 patients were found comparing speech and language therapy with an untreated group. The quality of the methods used in these trials was variable, with all studies failing in at least one critical area. All three of the controlled trials reported a positive effect of speech and language therapy for speech disorders in Parkinson's disease. Many of the outcome measures examined appeared to improve by a clinically significant amount after therapy. However, it should be noted that there were flaws in the methods used in these studies and only a small number of patients with Parkinson’s disease were examined. This means that there is insufficient evidence to absolutely prove or disprove the benefit of speech and language therapy for the treatment of speech disorders in Parkinson's disease patients, but lack of evidence does not mean lack of effect.

A large well designed placebo-controlled randomised trial is needed to assess the effectiveness of speech and language therapy for speech disorders in Parkinson's disease. Outcome measures with particular relevance to people with Parkinson’s disease should be chosen and the patients followed for at least six months to determine the duration of any improvement.

Speech and language therapy for speech problems in Parkinson’s disease

Herd CP;Tomlinson CL;Deane KHO;Brady MC;Smith CH;Sackley C;Clarke CE — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Herd CP, Tomlinson CL, Deane KHO, Brady MC, Smith CH, Sackley C, Clarke CE

Many people with Parkinson's disease suffer from disorders of speech. The most frequently reported speech problems are weak, hoarse, nasal or monotonous voice, imprecise articulation, slow or fast speech, difficulty starting speech, impaired stress or rhythm, stuttering and tremor. People with the condition also tend to give fewer non-verbal cues such as using facial expression to convey information. These disabilities tend to increase as the disease progresses and can lead to serious problems with communication.

This review compares the benefits of one form of speech and language therapy (SLT) versus another for individuals with Parkinson's disease. Relevant trials were identified by electronic searches of 16 biomedical literature databases, various registers of clinical trials and examination of the reference lists of identified studies and other reviews.

Only randomised controlled trials were included in this review. These are studies in which two groups of patients were compared, each group receiving a different form of SLT, with patients assigned to the groups in a random fashion to reduce potential for bias.

Six trials were found with a total of 159 patients. Methods varied so much that meta-analysis of the results was not possible. Considering the small number of patients and the methodological flaws in these studies, there is insufficient evidence to support the use of one form of SLT over another for the treatment of speech problems in individuals with Parkinson's disease.

Stem cell treatment following a heart attack

Clifford DM;Fisher SA;Brunskill SJ;Doree C;Mathur A;Watt S;Martin-Rendon E — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Clifford DM, Fisher SA, Brunskill SJ, Doree C, Mathur A, Watt S, Martin-Rendon E

Currently the standard treatment for people suffering a heart attack (due to a blockage in the artery supplying blood to the heart) is to directly open the artery with a tiny balloon in a procedure called primary angioplasty and to introduce a small tube into the artery to keep it open called a stent. The use of primary angioplasty and stents to reopen the blocked artery can lead to a 33% reduction in the mortality (death rate) associated with this condition. Recently, bone marrow stem/progenitor cells have been investigated as a new treatment that may prevent the damage to heart muscle caused by a heart attack in addition to the treatment offered by primary angioplasty. Analysis of randomised controlled trials to 2011 indicates that this new treatment may lead to some improvements over standard treatment as measured by tests of heart function in the short and long term. Over 1,700 patients have participated so far in the 33 trials included in this systematic review.

Sumatriptan (intranasal route of administration) for acute migraine attacks in adults

Derry CJ;Derry S;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Derry CJ, Derry S, Moore RA

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a nasal spray, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, although absorption of the drug occurs primarily in the gut rather than the nasal mucosa. This review found that a single intranasal dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 10 people (24%) taking sumatriptan 10 mg, compared with about 1 in 10 (10%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 5 in 10 people (50%) taking sumatriptan 10 mg, compared with approximately 3 in 10 (32%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those who took placebo. The 20 mg dose had greater efficacy, but may be associated with more adverse events, most of which were of short duration and mild or moderate in severity.

Sumatriptan (oral route of administration) for acute migraine attacks in adults

Derry CJ;Derry S;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Derry CJ, Derry S, Moore RA

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is widely available as an oral tablet. This review found that a single dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in about 3 in 10 people (32%) taking sumatriptan 100 mg, compared with about 1 in 10 (11%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in 6 in 10 people (61%) taking sumatriptan 100 mg, compared with about 3 in 10 (32%) taking placebo. Almost a quarter (24%) of people taking sumatriptan 100 mg had freedom from pain at two hours which was sustained during 24 hours without the use of rescue medication, compared with fewer than 1 in 10 (8%) taking placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those taking placebo. Adverse events were mostly of short duration and mild or moderate in severity, and were experienced by about 4 in 10 (43%) of people taking sumatriptan 100 mg, and by 2 in 10 (23%) taking placebo. The 50 mg dose had slightly lower efficacy, but was associated with fewer adverse events. Treating attacks while pain was still mild was more effective than treating established attacks with moderate or severe pain intensity.

Sumatriptan (rectal route of administration) for acute migraine attacks in adults

Derry CJ;Derry S;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Derry CJ, Derry S, Moore RA

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a rectal suppository in some countries, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting. This review found that a single dose administered rectally was effective in relieving migraine headache pain and functional disability. Pain was reduced from moderate or severe to no pain by two hours in approximately 2 in 5 people (41%) taking sumatriptan 25 mg, compared with about 1 in 6 (17%) taking placebo. Pain was reduced from moderate or severe to no worse than mild pain by two hours in roughly 2 in 3 people (71%) taking sumatriptan 25 mg, compared with approximately 1 in 3 (30%) taking placebo. In addition to relieving headache pain, sumatriptan 25 mg also relieved functional disability by two hours in about 2 in 5 people (41%), compared with about 1 in 6 (16%) taking placebo. There was not enough evidence to draw any conclusions about the incidence of adverse events or to compare rectal sumatriptan directly with any other active comparators.

Sumatriptan (subcutaneous route of administration) for acute migraine attacks in adults

Derry CJ;Derry S;Moore RA — Wed, 15 Feb 2012 00:00:00 +0100

New

Derry CJ, Derry S, Moore RA

Sumatriptan is one of the triptan family of drugs used to treat migraine attacks. It is available as a subcutaneous injection, and this route of administration may be preferable for individuals experiencing nausea and/or vomiting, or needing fast relief. This review found that a single subcutaneous dose was effective in relieving migraine headache pain and associated symptoms of nausea, sensitivity to light, and sensitivity to sound. Pain was reduced from moderate or severe to no pain by two hours in almost 6 in 10 people (59%) taking sumatriptan 6 mg, compared with about 1 in 7 (15%) taking placebo, and reduced from moderate or severe to no worse than mild pain by two hours in almost 8 in 10 people (79%) taking sumatriptan compared with about 3 in 10 (31%) taking placebo. Subcutaneous sumatriptan was fast-acting, and the majority of people experiencing pain relief had done so by one hour. About 3 in 10 (31%) people had freedom from pain at two hours which was sustained during the 24 hours postdose without the use of rescue medication, compared with about 1 in 7 (15%) with placebo. In addition to relieving headache pain, sumatriptan also relieved symptoms of nausea and sensitivity to light and sound by two hours in about half of those who took it, compared with about one-third of those taking placebo. Adverse events, most of which were of short duration and mild or moderate in severity, were more frequent with sumatriptan than with placebo.

Surfactant for bacterial pneumonia in term and late preterm infants

Tan K;Lai NM;Sharma A — Wed, 15 Feb 2012 00:00:00 +0100

New

Tan K, Lai NM, Sharma A

Bacterial pneumonia in preterm and term newborn babies can cause problems with the functioning of pulmonary surfactant, a complex combination of fats and proteins that lines the lung and causes the lung to work effectively. Disrupting surfactant function makes breathing very difficult for these infants. In this review, we did not find any suitable clinical trials to assess the benefits or harms of surfactant treatment in addition to standard intensive care in the treatment of babies with bacterial pneumonia. More research is needed to answer the question of whether surfactant treatment is beneficial for near-term and term infants with bacterial pneumonia.

Surgery for choanal atresia

Cedin AC;Atallah ÁN;Andriolo RB;Cruz OL;Pignatari SN — Wed, 15 Feb 2012 00:00:00 +0100

New

Cedin AC, Atallah ÁN, Andriolo RB, Cruz OL, Pignatari SN

Congenital (present from birth) choanal atresia is a rare abnormality characterized by narrowing or blockage of one or both sides of the nasal airway. It has an incidence of between 1 in 5000 and 1 in 8000 births and is two times more common in females. Choanal atresia is treated by surgery, which aims to open the nasal airway sufficiently, avoid harm to any structure in development and result in a low rate of restenosis (renarrowing) after the operation. The procedure should ideally enable the shortest possible surgery and hospitalization time, and minimize morbidity and mortality. Many different techniques and approaches have been described.

We looked for randomized controlled trials which have studied the effects of any surgical procedure for choanal atresia (one or both sides) in patients of any age. Our searches retrieved 46 reports of studies which had tested surgical approaches. However, we excluded all of them during the final selection process because their study designs did not meet the inclusion criteria for this review (i.e. they were not randomized controlled trials). There is therefore no definitive evidence, based on adequate studies, to demonstrate the potential advantages and disadvantages of any specific surgical technique for patients with choanal atresia over other techniques. Specialists should unify their efforts in multicenter randomized controlled trials testing the effectiveness and safety of different surgical techniques for patients with choanal atresia.

Sweet potato for type 2 diabetes mellitus

Ooi CP;Loke SC — Wed, 15 Feb 2012 00:00:00 +0100

New

Ooi CP, Loke SC

Sweet potato (Ipomoea batatas) is a plant found in the tropical and subtropical belts and is one of the most nutritious tropical and subtropical vegetables. Besides its popularity in the cuisines of countries in Asia-Pacific, Africa and North America, sweet potato is also used in traditional medicine practices for the treatment of diabetes mellitus. However, the current evidence does not warrant using the plant in treating this disease. This review of randomised controlled trials found only three studies of altogether very low quality evaluating the effects of sweet potato for type 2 diabetes mellitus. Two studies with 122 participants showed improved long-term metabolic control as measured by glycosylated haemoglobin A1c (HbA1c): At three to five months 4 g per day sweet potato preparations compared to placebo resulted in a -0.3% decrease of HbA1c which was statistically significant but not clinically relevant. The duration of treatment ranged from six weeks to five months and altogether 140 patients with type 2 diabetes mellitus participated in the studies. No study investigated diabetic complications, death from any cause, health-related quality of life, well-being, functional outcomes or costs. Adverse effects were mostly mild, including abdominal distension and pain. There are many varieties of sweet potato vegetables and preparations. More trials are needed to assess the quality of the various sweet potato preparations as well as to evaluate further the use of varieties of sweet potato in the diet of diabetic people.

The effects of water compared with other solutions for wound cleansing

Fernandez R;Griffiths R — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Fernandez R, Griffiths R

Water is frequently used for cleaning wounds to prevent infection. This can be tap water, distilled water, cooled boiled water or saline (salty water). Using tap water to cleanse acute wounds in adults does not increase the infection rate; however, there is no strong evidence that cleansing per se is better than not cleansing. The reviewers concluded that where tap water is high quality (drinkable), it may be as good as other methods such as sterile water or saline (salty) water (and more cost-effective), but more research is needed.

The evidence found did not indicate superiority of stapled over handsewn technique in colorectal anastomosis, regardless of the anastomotic level.

Neutzling CB;Lustosa SAS;Proenca IM;da Silva EMK;Matos D — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Neutzling CB, Lustosa SAS, Proenca IM, da Silva EMK, Matos D

The review with nine randomised controlled trials (1233 patients, 622 with stapling and 611 with the handsewing technique) compared the safety and effectiveness of stapled versus handsewn colorectal anastomosis surgery. Meta-analysis was performed using the risk difference and weighted mean difference, with corresponding 95% confidence intervals. Outcome measures were mortality, anastomotic dehiscence, narrowing (stricture), haemorrhage, need for reoperation, wound infection, anastomosis duration (time taken to perform the anastomosis) and hospital stay. No significant statistical differences were found except that stricture was more frequent with stapling (P < 0.05) and the time taken to perform the anastomosis was longer with handsewn techniques.

The role of the monoclonal antibody alemtuzumab for treatment of people with chronic lymphocytic leukaemia

Skoetz N;Bauer K;Elter T;Monsef I;Roloff V;Hallek M;Engert A — Wed, 15 Feb 2012 00:00:00 +0100

New

Skoetz N, Bauer K, Elter T, Monsef I, Roloff V, Hallek M, Engert A

Chronic lymphocytic leukaemia (CLL) is a cancer and accounts for 25% of all leukaemias. The disease is the most common cancer of the lymphatic system in Western countries and is characterised by a highly variable clinical course and prognosis. Some patients may have minimal or no symptoms for many years with a normal life expectancy, without requiring treatment. Others are symptomatic at diagnosis or early thereafter and can experience infectious and autoimmune complications, leading to a reduced lifespan. Standard treatment includes chemotherapy with one or more agents. Nowadays monoclonal antibodies are added, especially alemtuzumab and rituximab. However, the impact of these agents remains unclear, as there were hints for increased overall survival, but also risk for severe infections in non-randomised trials. In this systematic review we summarised and analysed the evidence from randomised controlled trials (RCTs) on efficacy and safety of alemtuzumab in the treatment of CLL. We searched several important medical databases such as CENTRAL, MEDLINE and EMBASE and found five RCTs fulfilling our pre-defined inclusion criteria. We included trials that compared alemtuzumab with no further therapy or with anti-cancer therapy in newly-diagnosed or relapsed patients with CLL. In total, 845 patients were treated within the five trials.

Two trials assessed whether alemtuzumab is favourable compared with no further therapy. One trial reported data on overall survival, showing a significant advantage for those patients receiving additional alemtuzumab. The time without progression was statistically significantly improved in both trials with alemtuzumab, but more patients had an infection, especially a virus infection (cytomegalovirus infection). Because of severe infections, one trial was closed prematurely.

Two trials evaluated alemtuzumab versus rituximab. Neither study reported data on survival or survival without a relapse of the disease. We found no statistically significant differences for response to therapy or for deaths during study treatment. One trial was stopped early due to an increase in mortality in the alemtuzumab arm.

In the fifth trial alemtuzumab was compared with chemotherapy (chlorambucil). In this trial no difference in survival could be detected until the last publication of the study. Alemtuzumab statistically significantly improves the survival without a relapse, the time to anti-cancer treatment for relapse, and the response rate. Again, more infections occurred in the patients treated with alemtuzumab, especially infections with the cytomegalovirus that could lead to lung and retina infections.

In summary, the currently available evidence suggests an survival advantage for alemtuzumab compared with no further therapy, but an increased risk for infections in general and for cytomegalovirus.

The timing of inhalation of hypertonic saline in people with cystic fibrosis

Elkins M;Dentice R — Wed, 15 Feb 2012 00:00:00 +0100

New

Elkins M, Dentice R

Inhalation of a strong, sterile, salt water solution (known as hypertonic saline) through a nebuliser improves the physical properties of sputum and stimulates cough in people with cystic fibrosis. Regular inhalation improves the clinical outcomes of people with cystic fibrosis. It is not certain whether it is better to inhale hypertonic saline before or after clearing the airways with physical techniques, nor whether it is better to inhale it in the morning or in the evening. We looked for trials that compared these different timing regimens, but were unable to find any such trials. In the absence of this evidence, people with cystic fibrosis might be advised to inhale hypertonic saline before airway clearance, because this is the only timing regimen with established efficacy. Because the long-term efficacy of hypertonic saline has only been established for twice-daily inhalations, clinicians should advise patients to inhale hypertonic saline both in the morning and in the evening. However, if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability until further evidence is available.

There is some evidence that human growth hormone may help reduce growth problems in children with chronic kidney disease

Hodson EM;Willis NS;Craig JC — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Hodson EM, Willis NS, Craig JC

The kidneys filter blood. Children with chronic kidney disease (CKD) may progress to end-stage kidney failure and need their blood filtered by machine (dialysis) or they need a kidney transplant. CKD can stunt growth in children. Growth hormone (rhGH) has been used to help children grow to a more average height for their age but rhGH may have adverse effects including added risk of transplant rejection and high pressure in the brain. This review of 16 studies enrolling 809 children found that rhGH increased height in children with CKD by about 4 cm after 1 year and by a further 2 cm after 2 years of treatment compared with no treatment. The frequency of reported side effects of rhGH was generally similar to that of the control group.

Treatment for spasticity (muscle tightness and spasm) in people with amyotrophic lateral sclerosis/motor neuron disease

Ashworth NL;Satkunam LE;Deforge D — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Ashworth NL, Satkunam LE, Deforge D

Spasticity commonly causes a 'stiffness' or 'tightness' in the already weakened muscles of a person with amyotrophic lateral sclerosis (also known as motor neuron disease). This can lead to even greater difficulties in the ability to perform day-to-day activities. This review found only one randomized trial of treatment for spasticity in motor neuron disease, which involved 25 participants, and no further trials have been found in subsequent updates. There were a number of issues with the design of the study which unfortunately reduced the certainty of the findings. At three months participants performing the 15 minute twice daily exercises had significantly less spasticity overall than control participants (mean reduction of -0.43, 95% confidence interval (CI) -1.03 to +0.17 in the treatment group versus an increase of +0.25, 95% CI -0.46 to +0.96 in control) but the mean change between groups was not significant, as measured by the Ashworth scale (a scale of spasticity, with a range of 0 to 5, where higher is worse). The trial was too small to determine whether individualized moderate intensity endurance type exercises for the trunk and limbs are beneficial or harmful. No side effects from exercise were reported. No other randomized trials of different treatments or therapies were found. Further research is needed to determine if exercise or other therapies such as anti-spasticity medication are beneficial or harmful.

Treatments for erosive lichen planus affecting mucosal sites

Cheng S;Kirtschig G;Cooper S;Thornhill M;Leonardi-Bee J;Murphy R — Wed, 15 Feb 2012 00:00:00 +0100

New

Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R

Erosive lichen planus (ELP) is a condition that affects the mouth, oesophagus (food pipe or gullet), and anogenital region. It is caused by an over-active immune system. It is often more painful and debilitating than the non-erosive types of lichen planus. Depending on the site involved, affected individuals may experience pain, and difficulty eating; passing urine; or having sexual intercourse. Treatment is difficult and aimed at controlling symptoms, rather than cure. Several creams and tablets have been used with varying results.

This review looked at the effectiveness of treatments for ELP. Fifteen studies were included in this review, giving a total of 473 participants with ELP. All involved oral, but not genital, disease. Many studies were excluded either because they were not randomised controlled trials (where participants are divided into two groups at random) or because they recruited participants with all types of lichen planus, rather than just the erosive subtypes. All of these studies recruited small numbers of participants (12 to 94) and used a variety of different assessment methods and timings; hence, it was not possible to combine or compare results between studies directly.

We found only weak evidence for the effectiveness of any of the treatments for oral ELP. None of the studies involved genital or oesophageal disease; hence, no evidence was found for the treatment of these conditions. One small study found that 0.025% clobetasol propionate (a very potent topical steroid) administered as a spray significantly reduced pain when compared to ointment. In another study, a significant difference in pain was seen in the small subgroup of 11 ELP participants, favouring ciclosporin solution over 0.1% triamcinolone acetonide in orabase (a potent topical steroid). In a study involving 45 ELP participants, aloe vera gel was 6 times more likely to result in at least a 50% improvement in pain symptoms compared to placebo.

Several side-effects were reported, but none were serious. With topical corticosteroids, the main side-effects were oral candida (yeast) infection and pain or discomfort in the upper abdomen. Temporary burning was a common side-effect reported with tacrolimus 0.1% ointment and pimecrolimus 0.1% cream.

Overall, there was no overwhelming evidence for the effectiveness of any single treatment, including topical steroids, which are the widely accepted first-line therapy for ELP. This was mainly due to the lack of good-quality, well-conducted trials and small participant numbers.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence following bladder surgery

Cody JD;Nabi G;Dublin N;McClinton S;Neal DE;Pickard R;Yong SM — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Cody JD, Nabi G, Dublin N, McClinton S, Neal DE, Pickard R, Yong SM

The normal urinary bladder is a hollow muscular organ that lies deep in the pelvis. It functions through the balanced activity of many inter-related nerves and muscles that contain or empty urine as needed. If the bladder has been damaged by disease, surgery can be performed to divert the urine from the bladder (urinary diversion), to reconstruct the bladder or to replace the bladder with intestinal segments. The review did not find enough evidence from trials to show which surgical options are the most effective. One small trial suggested that the ileum bowel segment (small bowel) may be better compared to ileocolonic bowel segment (combination of small and large bowel) for night time incontinence. More research is needed to determine the most effective surgical methods for urinary diversion, reconstruction or replacement of the urinary bladder that has been damaged by disease.

Use of the antioxidant supplement Pycnogenol^® to treat a variety of chronic disorders

Schoonees A;Visser J;Musekiwa A;Volmink J — Wed, 15 Feb 2012 00:00:00 +0100

New

Schoonees A, Visser J, Musekiwa A, Volmink J

Pycnogenol® is a herbal dietary supplement extracted from French maritime pine bark whose main ingredient is procyanidin. Procyanidin is a powerful antioxidant also found in food such as grapes, berries, pomegranates, red wine and various nuts. Supplements containing procyanidin are widely marketed worldwide for the promotion of health, and for the prevention and treatment of chronic disorders. The rationale for this is that antioxidants neutralise reactive oxygen species (ROS; frequently referred to as "free radicals") which, apart from performing important bodily functions, can cause damage to cells and tissues if present in excessive amounts. Available supplements vary in the source and quantity of procyanidin, as well as in number and type of other ingredients they contain. We chose to focus on Pycnogenol® as this supplement is a standardised product, many trials have been conducted, and it is extensively marketed internationally. Our review aimed to assess the efficacy and safety of Pycnogenol® as a treatment for chronic disorders. We identified 15 eligible randomised controlled trials with a total of 791 participants which addressed seven different chronic conditions: asthma (two studies); attention deficit hyperactivity disorder (one study), chronic venous insufficiency (two studies), diabetes (four studies), erectile dysfunction (one study), hypertension (two studies) and osteoarthritis (three studies). Due to small sample size, limited number of trials per condition, variation in outcomes evaluated and outcome measures used, as well as the risk of bias in the included studies, no definite conclusions regarding the efficacy and safety of Pycnogenol® are possible.

Using the combined vaccine for protection of children against measles, mumps and rubella

Demicheli V;Rivetti A;Debalini MG;Di Pietrantonj C — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C

Measles, mumps and rubella (MMR) are three very dangerous infectious diseases which cause severe morbidity, disability and death in low-income countries.

Based on the evidence provided by three cohort studies (3104 participants), vaccination with one dose of MMR vaccine is at least 95% effective in preventing clinical measles among preschool children; in schoolchildren and adolescents at least one dose of MMR vaccine was 98% effective in preventing laboratory-confirmed measles cases; one or two MMR doses were respectively 92% and 95% effective in preventing secondary measles cases.

At least one dose of MMR vaccine is effective in preventing clinical mumps among children and adolescents when prepared with Jeryl Lynn strains (vaccine effectiveness = 69% to 81%, one cohort and one case-control study, 1656 participants), as well as when prepared with Urabe strain (vaccine effectiveness = 70% to 75%, one cohort and one case-control study, 1964 participants). Effectiveness against laboratory-confirmed mumps in children and adolescents was estimated to be between 64% to 66% for one and 83% to 88% for two doses of Jeryl Lynn MMR (two case-control studies, 1664 participants) and 87% for Urabe-containing MMR (one cohort study, 48 participants). Vaccination with Urabe MMR confers protection against secondary mumps infection (vaccine effectiveness = 73%, one cohort study, 147 participants).

We identified no studies assessing the effectiveness of MMR vaccine against clinical or laboratory-confirmed rubella.

Results from two very large case series studies involving about 1,500,000 children who were given the MMR vaccine containing Urabe or Leningrad-Zagreb strains show this vaccine to be associated with aseptic meningitis; whereas administration of the vaccine containing Moraten, Jeryl Lynn, Wistar RA, RIT 4385 strains is associated with febrile convulsion in children aged below five years (one person-time cohort study, 537,171 participants; two self controlled case series studies, 1001 participants). The MMR vaccine could also be associated with idiopathic thrombocytopaenic purpura (two case-controls, 2450 participants, one self controlled case series, 63 participants).

We could assess no significant association between MMR immunisation and the following conditions: autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, or bacterial or viral infections. The methodological quality of many of the included studies made it difficult to generalise their results.

The glossary of study designs is available in the full-text review.

Using wound drains after incisional hernia repair

Gurusamy KS;Allen VB;Samraj K — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Gurusamy KS, Allen VB, Samraj K

Incisional hernias are caused by the failure of the wall of the abdomen to close after abdominal surgery. This leaves a hole through which the viscera (guts) protrude. Hernias are repaired with further surgery, during which the insertion of a drain to remove excess fluid is common practice. It is not known whether or not these drains help the wounds to heal. Drains may produce undesired results such as an increased risk of infection, pain, and an increased length of hospital stay after surgery. We reviewed all the available trial evidence to see whether drains help or hinder recovery after operations for incisional hernia repair. We found that no trials that compared people who had drains inserted for this type of surgery against those who did not. One trial compared two types of drain against each other, and both models of drain performed similarly well. Further trials need to be carried out before being able to answer the question about the benefits, or otherwise, of drains inserted during repair of incisional hernias.

Vaccines for preventing plague

Jefferson T;Demicheli V;Pratt M — Wed, 15 Feb 2012 00:00:00 +0100

Updated

Jefferson T, Demicheli V, Pratt M

Plague is a rare disease now, but can be life threatening. It is transmitted by fleas and related to rat infestation. There are different forms of the disease, but they can all lead to blood poisoning and to death, although antibiotics are effective against the bacterium that causes it. Vaccines are available for use in laboratory staff working on the disease; however when the authors searched the literature they found no studies of sufficient quality to be included in this review. We therefore cannot make confident decisions about the effectiveness or tolerability of any plague vaccines.

Vaccines for preventing rotavirus diarrhoea: vaccines in use

Wed, 15 Feb 2012 00:00:00 +0100

Updated

Soares-Weiser K, MacLehose H, Bergman H, Ben-Aharon I, Nagpal S, Goldberg E, Pitan F, Cunliffe N

Rotavirus infection is one of the most common causes of diarrhoea in infants and young children, and the symptoms can range from mild illness, to hospitalization, and death. Rotavirus infections cause about half a million deaths per year in children younger than five years, mainly in low- and middle-income countries. Since 2009, the World Health Organization (WHO) has recommended rotavirus vaccine be included in all national immunization programmes.

This review evaluates a monovalent rotavirus vaccine (RV1; Rotarix, GlaxoSmithKline Biologicals) and a pentavalent rotavirus vaccine (RV5; RotaTeq, Merck & Co., Inc.). These vaccines have been evaluated in several large trials and are approved for use in many countries. No trials of the Lanzhou lamb rotavirus vaccine (LLR; Lanzhou Institute of Biomedical Products) were found; this vaccine is used in China only.

The review includes 43 trials with 190,551 participants; all trials compared a rotavirus vaccine with placebo. The vaccines tested were RV1 (31 trials with 105,959 participants) and RV5 (12 trials with 84,592 participants). The trials took place in a number of worldwide locations.

Compared to placebo, RV1 probably prevents 70% of all cases of rotavirus diarrhoea, and 80% of severe episodes during the first and second year of life. RV5 reduced any rotavirus diarrhoea or severe cases by more than 70% in the first year, and by approximately 50% in the second year. Both vaccines reduced severe diarrhoea from all causes by at least 40%. The vaccines when tested against placebo gave similar numbers of adverse events such as deaths, reactions to the vaccine, and other events that required discontinuation of the vaccination schedule.

In conclusion, data from this review show that RV1 and RV5 are effective vaccines, and support the WHO's recommendation to include rotavirus vaccination into national childhood immunization programmes, especially in countries with a high burden of diarrhoeal deaths in children younger than five years. Continued safety monitoring is advised in countries where vaccines are routinely used.

Vitamin D supplementation for women during pregnancy

De-Regil LM;Palacios C;Ansary A;Kulier R;Peña-Rosas JP — Wed, 15 Feb 2012 00:00:00 +0100

New

De-Regil LM, Palacios C, Ansary A, Kulier R, Peña-Rosas JP

Vitamin D is produced by the human body from exposure to sunlight and can also be consumed from foods such as fish-liver oils, fatty fish, mushrooms, egg yolks, and liver. Vitamin D has many functions in the body; it helps maintain bone integrity and calcium homeostasis.

During pregnancy, vitamin D deficiency or insufficiency may develop. Vitamin D supplementation during pregnancy has been suggested to safely improve pregnancy and infant outcomes. This review included six randomised controlled trials. Five trials involving 623 women compared the effects of vitamin D alone versus no supplementation or a placebo and one trial with 400 women compared the effects of vitamin D and calcium with no supplementation.

The results show that the provision of vitamin D supplements during pregnancy improves the women’s vitamin D levels, as measured by 25-hydroxyvitamin D levels, at term. However, the clinical significance of this finding is yet to be determined as there is no evidence that vitamin D supplementation prevents pre-eclampsia, gestational diabetes, impaired glucose tolerance, caesarean section, gestational hypertension, or death in the mothers; or preterm birth, stillbirth, neonatal death, neonatal admission to intensive care unit, newborns with low Apgar score or neonatal infection.

Data from three trials involving 463 women show a trend for women who receive vitamin D supplementation during pregnancy to more frequently have a baby with a birthweight below 2500 grams than those women receiving no treatment or placebo, although the statistical significance was borderline.

The number of trials and outcomes reported are too limited, and in general are of low quality, to draw conclusions on the usefulness and safety of this intervention as a part of routine antenatal care. Further rigorous randomised trials are required to evaluate the role of vitamin D supplementation in pregnancy.

Whole-body vibration platform training in patients with neurodegenerative diseases

Wed, 15 Feb 2012 00:00:00 +0100

New

Sitjà Rabert M, Rigau Comas D, Fort Vanmeerhaeghe A, Santoyo Medina C, Roqué i Figuls M, Romero-Rodríguez D, Bonfill Cosp X

Rehabilitation is considered to be a key symptomatic and supportive treatment for neurodegenerative diseases. Exercise training using vibratory platform (whole body vibration) has been recently introduced as a complementary treatment to rehabilitation.This review identified ten trials performing whole body vibration (WBV) in neurodegenerative diseases: six in Parkinson's disease and four in multiple sclerosis. Diversity in treatments and outcomes measures makes difficult to quantitatively compare the effect of WBV intervention across studies and to assess its efficacy. There is insufficient evidence to determine the potential benefits of WBV training in functional performance according to activities of daily life, body balance, signs and symptoms of disease, muscle performance, and quality of life in patients with neurodegenerative diseases. Adverse events were poorly reported in the included studies, but this kind of training seems to be a safe intervention. These conclusions are based on a small number of studies with a limited methodological quality.