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PubMed2004

A systematic review of Swedish research in orthodontics during the past decade.

The aims of this systematic review were to identify the study designs and topics of Swedish orthodontic articles, to elucidate their international position, and to verify in which scientific journals the articles had been published in the past decade. A search of the Medline database for papers published between 1992 and 2002 was made using the Medical Search Heading terms 'orthodontics', 'malocclusion', 'cephalometry', and 'facial bones and growth'. Two independent reviewers selected the articles of Swedish origin and categorized each article according to research design and principal topic. Overall, 15,571 articles in orthodontic research were found, and the Swedish contribution was 1.9% with the majority of these (71.5%) being submitted by universities. Most of the Swedish articles (84.5%) had been published in 10 journals and many high-quality studies with orthodontic interest were published in non-orthodontic journals with higher impact factor scores than the orthodontic journals. Every second study was prospective, and of these, 15 (5.2% of all Swedish articles) were randomized clinical trials (RCTs). It was found that nearly every third study, prospective as well as retrospective, was uncontrolled. The main classification was treatment studies (51.9%), followed by development (18.6%) and diagnostic information (10.7%) studies. Thus, the majority of the articles evaluated therapeutic interventions; however, although the RCT is the preferred study design in evaluation studies, few used this method. In an era focused on evidence-based medicine, studies with an RCT design will be the future challenge for research in the field of orthodontics.

Dental Research↗
PubMed2000

Amnioinfusion for meconium-stained liquor in labour.

BACKGROUND: Amnioinfusion aims to prevent or relieve umbilical cord compression during labour by infusing a solution into the uterine cavity. It is also thought to dilute meconium when present in the amniotic fluid and so reduce the risk of meconium aspiration. However it may be that the mechanism of effect is that it corrects oligohydramnios (reduced amniotic fluid), for which thick meconium staining is a marker. OBJECTIVES: The objective of this review was to assess the effects of amnioinfusion for meconium-stained liquor on perinatal outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. SELECTION CRITERIA: Randomised trials comparing amnioinfusion with no amnioinfusion for women in labour with moderate or thick meconium-staining of the amniotic fluid. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS: Ten studies, most involving small numbers of participants, were included. Under standard perinatal surveillance, amnioinfusion was associated with a reduction in the following: heavy meconium staining of the liquor (relative risk 0.03, 95% confidence interval 0.01 to 0.15); variable fetal heart rate deceleration (relative risk 0.47, 95% confidence interval 0.24 to 0. 90); and a trend to reduced caesarean section overall (relative risk 0.83, 95% confidence interval 0.69 to 1.00). No perinatal deaths were reported. Under limited perinatal surveillance, amnioinfusion was associated with a reduction in the following: meconium aspiration syndrome (relative risk 0.24, 95% confidence interval 0. 12 to 0.48); neonatal hypoxic ischaemic encephalopathy (relative risk 0.07, 95% confidence interval 0.01 to 0.56) and neonatal ventilation or intensive care unit admission (relative risk 0.56, 95% confidence interval 0.39 to 0.79); there was a trend towards reduced perinatal mortality (relative risk 0.34, 95% confidence interval 0.11 to 1.06). REVIEWER'S CONCLUSIONS: Amnioinfusion is associated with improvements in perinatal outcome, particularly in settings where facilities for perinatal surveillance are limited. The trials reviewed are too small to address the possibility of rare but serious maternal adverse effects of amnioinfusion.

Amnion↗
PubMed2000

Hormonal placental function tests for fetal assessment in high risk pregnancies.

BACKGROUND: Biochemical tests of fetal well-being such as placental hormone levels have not always shown direct benefits for mothers and babies. OBJECTIVES: The objective of this review was to assess the effects of measuring placental hormone levels during high risk pregnancies. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and MEDLINE. We also contacted study authors. SELECTION CRITERIA: Adequately controlled trials comparing availability with no availability of hormone placental tests in high risk pregnancy. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted by two reviewers and this was checked by a colleague. Study authors were contacted for additional information. MAIN RESULTS: Two trials involving 3355 women were included. Methodological quality of the trials was acceptable, but results for only 230 out of 2733 women (abnormal hormone levels) were available from one trial. One trial compared oestriol levels reported promptly with levels measured but not reported. The overall perinatal mortality rate was 30.5 per 1000 live births weighing 500 grams or more. No beneficial effects of oestriol measurement on fetal outcome could be identified (odds ratio of perinatal death 0.87, 95% confidence interval 0.35 to 2.18). For abnormal test results only, the reported oestriol group showed a statistically non-significant trend to less perinatal mortality (odds ratio 0.48, 95% confidence interval 0.15 to 1.60). The other trial compared human placental lactogen measurements reported promptly with measurements not reported until after pregnancy. For abnormal test results, the reported group showed significantly less perinatal mortality with four (3.4%) deaths compared to 17 (15%) in the control group (odds ratio 0.25, 95% confidence interval 0.10 to 0.61). Data from normal test results was not available for this trial. REVIEWER'S CONCLUSIONS: The measurement of human placental lactogen levels may be of some value in high risk pregnancies, but there is not enough evidence to evaluate the use of hormone placental tests generally.

Female↗
PubMed2000

Hydergine for dementia.

BACKGROUND: Currently hydergine is used almost exclusively for treating patients with either dementia, or 'age-related' cognitive symptoms. Since the early eighties there have been over a dozen more clinical trials, yet hydergine's efficacy remains uncertain. Although previous reviews offer generally favorable support for hydergine's efficacy, they were, however, limited by a bias with respect to the particular clinical studies chosen (eg, the inclusion of case reports, and uncontrolled trials), and by authors' impressionistic assessments of results. Not surprisingly, there has been a lack of consensus among reviewers with regard to the efficacy of hydergine. In 1994, a meta-analysis was published by the present reviewers who reported that overall, hydergine was more effective than placebo. However they also observed that the statistical evidence for efficacy in 'possible or probable Alzheimer's disease' patients was so modest that one additional statistically non-significant trial would have reduced the results to non significance. OBJECTIVES: Because of uncertainty surrounding the efficacy of hydergine, the goals of this overview were to assess its overall effect in patients with possible dementia, and to investigate potential moderators of an effect. SEARCH STRATEGY: The Cochrane Dementia Group Register of Clinical Trials was searched using the terms 'hydergine', 'ergoloids,' 'ergoloid mesylates,' 'dihydroergocristine,' 'dihydroergocryptine,' 'dihydroergotoxine,' and 'dihydroergocornine. MEDLINE, EMBASE, and two proprietary databases were searched also. Published reviews were inspected for further sources. SELECTION CRITERIA: Trials to be included must be randomized, double-blind, parallel-group, and unconfounded comparisons of hydergine with placebo for a treatment duration of greater than 1 week in subjects with dementia or symptoms consistent with dementia. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the reviewers, pooled where appropriate and possible, and the pooled odds ratios (95%CI) or the average differences (95%CI) were estimated. Where possible, intention-to-treat data were used. Outcomes of interest included clinical global impressions of change and comprehensive rating scales. Potential moderating variables of a treatment effect included: inpatient/outpatient status, trial duration, age, sex, medication dose, publication year, and diagnostic grouping. MAIN RESULTS: There were a total of nineteen trials that met inclusion criteria and that had data sufficient for analysis. Thirteen trials reported sufficient information to use a global rating of improvement and nine trials provided information on a comprehensive rating scale. Three trials provided both outcome measures. It was not possible to use many of the published results in a combined analysis owing to the lack of sufficient data to perform statistical analyses. For the twelve trials that used global ratings, there was a significant effect favoring hydergine (OR 3.78, 95%CI, 2.72-5.27). For the nine trials that used comprehensive ratings, there was a significant mean difference favoring hydergine (WMD 0.96, 95%CI, 0. 54-1.37). Hydergine was well tolerated in these trials, with 78% of randomized subjects available for data analyses. Greater effect sizes on global ratings were associated with younger age, and possibly higher dose, although most of the subgroup analyses were statistically insignificant. REVIEWER'S CONCLUSIONS: As in an earlier systematic review, we found hydergine to show significant treatment effects when assessed by either global ratings or comprehensive rating scales (based here on a smaller set of trials than in the earlier published systematic review because trials were required to have data that could conform with MetaView, the Cochrane Collaboration statistics software). The small number of trials available for analysis, however, limited the ability of subgroup analyses to identify statistically significant modera

Aged↗
PubMed2000

Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding.

BACKGROUND: Heavy menstrual bleeding is an important cause of ill health in premenopausal women. Although surgery is often used as a treatment, a range of medical therapies are also available. Nonsteroidal anti-inflammatory drugs or prostaglandin synthetase inhibitors reduce prostaglandin levels which are elevated in women with excessive menstrual bleeding and also may have a beneficial effect on dysmenorrhoea. OBJECTIVES: The primary objective of this review was to investigate the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) in achieving a reduction in menstrual blood loss in women of reproductive years with heavy menstrual bleeding (HMB). SEARCH STRATEGY: Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Subfertility Group Register of Trials, MEDLINE, EMBASE, PsychLIT, Current Contents, Biological Abstracts, Social Sciences Index and CINAHL were performed. Attempts were also made to identify trials from citation lists of review articles and drug companies were approached for unpublished data. In most cases, the first author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of individual NSAIDs with either each other, placebo or other medical treatments in women of reproductive years with regular heavy periods measured either objectively or subjectively and with no pathological or iatrogenic (treatment induced) causes for their heavy menstrual blood loss. DATA COLLECTION AND ANALYSIS: Sixteen RCTs were identified that fulfilled the inclusion criteria for this review. The reviewers extracted the data independently and odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data of nine trials. The remaining seven trials were of crossover design with data unsuitable for pooling and their individual results were described in text form. MAIN RESULTS: As a group, NSAIDs were more effective than placebo at reducing heavy menstrual bleeding but less effective than either tranexamic acid or danazol. Treatment with danazol caused a shorter duration of menstruation and more adverse events than NSAIDs but this did not appear to affect the acceptability of treatment. There was a non significant trend towards greater efficacy of NSAIDs compared to oral progestogen (luteal phase) and ethamsylate but no differences were demonstrated between NSAIDs and the progesterone releasing intra-uterine system (IUS) and the oral contraceptive pill, although these results were based on very small studies. There was no evidence of a difference between the individual NSAIDs (naproxen and mefenamic acid) in reducing HMB. REVIEWER'S CONCLUSIONS: NSAIDs reduce heavy menstrual bleeding when compared with placebo but are less effective than either tranexamic acid or danazol. However, adverse events are more severe with danazol therapy. In the limited number of small scale studies suitable for evaluation, no significant difference in efficacy was demonstrated between NSAIDs and other medical treatments such as oral progestogen given in the luteal phase, ethamsylate, oral contraceptive pill and the progesterone releasing IUS.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2000

Day care for pre-school children.

BACKGROUND: The debate about how, where and by whom young children should be looked after is one which has occupied much social policy and media attention in recent years. Mothers undertake most of the care of young children. Internationally, out-of-home day-care provision ranges widely. These different levels of provision are not simply a response to different levels of demand for day-care, but reflect cultural and economic interests concerning the welfare of children, the need to promote mothers' participation in paid work, and the importance of socialising children into society's values. At a time when a decline in family values is held responsible for a range of social problems, the day-care debate has a special prominence. OBJECTIVES: To quantify the effects of out-of-home day-care for preschool children on educational, health and welfare outcomes for children and their families. SEARCH STRATEGY: Randomised controlled trials of day-care for pre-school children were identified using electronic databases, hand searches of relevant literature, and contact with authors. SELECTION CRITERIA: Studies were included in the review if the intervention involved the provision of non-parental day care for children under 5 years of age, and the evaluation design was that of a randomised or quasi-randomised controlled trial. DATA COLLECTION AND ANALYSIS: A total of eight trials were identified after examining 920 abstracts and 19 books. The trials were assessed for methodological quality. MAIN RESULTS: Day-care increases children's IQ, and has beneficial effects on behavioural development and school achievement. Long-term follow up demonstrates increased employment, lower teenage pregnancy rates, higher socio-economic status and decreased criminal behaviour. There are positive effects on mothers' education, employment and interaction with children. Effects on fathers have not been examined. Few studies look at a range of outcomes spanning the health, education and welfare domains. Most of the trials combined non-parental day-care with some element of parent training or education (mostly targeted at mothers); they did not disentangle the possible effects of these two interventions. The trials had other significant methodological weaknesses, pointing to the importance of improving on study design in this field. All the trials were carried out in the USA. REVIEWER'S CONCLUSIONS: Day care has beneficial effect on children's development, school success and adult life patterns. To date, all randomised trials have been conducted among disadvantaged populations in the USA. The extent to which the results are generaliseable to other cultures and socioeconomic groups has yet to be evaluated.

Child Day Care Centers↗
PubMed2000

Antibiotics for preventing pneumonia in children with measles.

BACKGROUND: Measles causes more than a million deaths a year, of which most are children under five years of age who die from pneumonia. OBJECTIVES: The objective of this review was to assess the effects of antibiotics given to children with measles on reducing pneumonia or mortality, and to assess whether antibiotics should be given to all children with measles in communities with a high fatality rate. SEARCH STRATEGY: We searched MEDLINE (1966 - 1999), EMBASE (1980-1999) and the specialized trials register of the Acute Respiratory Infections Group in August 1999, and all relevant journals in the University of Melbourne medical library for the years 1935-46. SELECTION CRITERIA: Randomised or controlled trials of antibiotics for children with measles. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: Six trials with 1304 children were included. All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls. REVIEWER'S CONCLUSIONS: The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

Anti-Bacterial Agents↗
PubMed2000

Massage for low back pain.

BACKGROUND: Low back pain is one of the most common and costly musculoskeletal problems in modern societies. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function. OBJECTIVES: To assess the effects of massage therapy for non-specific low back pain. SEARCH STRATEGY: We searched Medline, Embase, Cochrane Controlled Trials Register, Healthstar, CINAHL and Dissertation abstracts from 1966 to 1999 with no language restrictions. References in the included studies and in reviews of the literature were also screened. Contact with content experts and massage associations were also made. SELECTION CRITERIA: This review included randomized, quasi-randomized or controlled clinical trials that investigated the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. DATA COLLECTION AND ANALYSIS: One reviewer applied the selection criteria and extracted the data. Two reviewers (one blinded to authors, institutions and journals) independently assessed the quality of each trial. A qualitative analysis (best-evidence synthesis) was performed due to clinical heterogeneity among the included trials and insufficient data reported. MAIN RESULTS: Four randomized controlled trials met the inclusion criteria. Two trials were of high and two of low methodological quality. None evaluated massage as the main intervention. Rather, it was the control intervention in studies evaluating manipulation, electrical stimulation, and a lumbar corset. There is limited evidence showing that massage is less effective than manipulation immediately after the first session and moderate evidence showing it is less effective than TENS during the course of sessions in relieving pain and improving activity. At the completion of treatment and at 3 weeks after discharge there is no difference among massage and manipulation, electrical stimulation or corsets, but this evidence is limited. REVIEWER'S CONCLUSIONS: Based on the studies reviewed, there is insufficient evidence to recommend massage as a stand-alone treatment for non-specific low back pain. There is a need for high quality controlled trials to further evaluate the effects of massage for this condition.

Adult↗
PubMed2000

Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia.

BACKGROUND: Chronic antipsychotic drug treatment may cause tardive dyskinesia (TD), a long-term movement disorder. The gamma-aminobutyric acid (GABA) agonist drugs have been trialed as a treatment for TD, but these drugs have intense sedative properties and can possibly exacerbate psychotic symptoms. OBJECTIVES: To determine the effects of GABA agonist drugs (baclofen, gamma-vinyl-GABA, gamma-acetylenic-GABA, progabide, muscimol, sodium valproate and tetrahydroisoxazolopyridine (THIP)) in people with neuroleptic-induced tardive dyskinesia (TD) and schizophrenia or other chronic mental illnesses. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1998), The Cochrane Library CENTRAL (1998), Cochrane Schizophrenia Group's Register of Trials (1998), EMBASE (1980-1998), LILACS (1982-1996), MEDLINE (1966-1998), PsycLIT (1974-1998), and SCISEARCH were undertaken. References of all identified studies were searched for further trial citations. First authors of each included trial were contacted. SELECTION CRITERIA: The inclusion criteria for all relevant randomised studies were that they should focus on people with schizophrenia or other chronic mental illnesses, with neuroleptic-induced TD and compare the use of GABA agonist drugs to placebo or no intervention. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently and the odds ratio (OR) and its 95% confidence interval (CI) or the weighted mean difference with 95% CI were estimated. The reviewers assumed that people who dropped out had no improvement. MAIN RESULTS: Eight studies were able to be included. Results were equivocal, showing only a tendency for clinical improvement for those using GABA agonist drugs but, when analysis of any improvement (rather than clinical improvement) was performed, a significant reduction was noted in the GABA group (OR 0.36 CI 0.15-0.85). This suggests that for every 10 people treated with GABA drugs one person would benefit with a reduction in TD symptoms. People using the interventions had more confusion (OR 7.4 CI 1.3-40.9) and sedation (OR 3.0 CI 1.2-7.6). The numbers of people needed to treat to cause one extra person to experience these side effects were three and six, respectively. Tendency for more deterioration of the TD symptoms (OR 1.72 CI 0. 54-5.5), deterioration of the mental state (OR 3.07 CI 0.78-12.05), and to drop out before the end of the trial (OR 2.05 CI 0.8-5.21) were also observed in those using GABA agonists. REVIEWER'S CONCLUSIONS: No clear statement about the efficacy of GABA agonist drugs could be provided. From the combined data, GABA agonist drugs tend to be associated with some degree of improvement in TD symptoms, but also with side effects such as confusion and sedation and a deterioration of the person's mental state.

Antipsychotic Agents↗
PubMed2000

Antibiotics for acute bronchitis.

BACKGROUND: Antibiotic treatment of acute bronchitis, which is one of the most common illnesses seen in primary care, is controversial. Most clinicians prescribe antibiotics in spite of expert recommendations against this practice. OBJECTIVES: People with acute bronchitis may show little evidence of bacterial infection. If effective, antibiotics could shorten the course of the disease. However if they are not effective, the risk of antibiotic resistance may be increased. The objective of this review was to assess the effects of antibiotic treatment for patients with a clinical diagnosis of acute bronchitis. SEARCH STRATEGY: We searched Medline, Embase, reference lists of articles and the authors' personal collections up to 1996, and Scisearch from 1989 to 1996. SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy with placebo in acute bronchitis. DATA COLLECTION AND ANALYSIS: At least two reviewers extracted data and assessed trial quality. MAIN RESULTS: Eight trials involving 750 patients aged eight to over 65 and including smokers and non-smokers were included. The quality of the trials was variable. A variety of outcome measures were assessed. In many cases, only outcomes that showed a statistically significant difference between groups were reported. Overall, patients receiving antibiotics had slightly better outcomes than did those receiving placebo. They were less likely to report feeling unwell at a follow up visit (odds ratio 0.42, 95% confidence interval 0.22 to 0.82), to show no improvement on physician assessment (odds ratio 0.43; 0.23 to 0.79), or to have abnormal lung findings (odds ratio 0.33, 95% confidence interval 0.13 to 0.86), and had a more rapid return to work or usual activities (weighted mean difference 0.7 days earlier, 95% confidence interval 0.2 to 1. 3). Antibiotic-treated patients reported significantly more adverse effects (odds ratio 1.64; 1.05 to 2.57) such as nausea, vomiting, headache, skin rash or vaginitis. REVIEWER'S CONCLUSIONS: Antibiotics appear to have a modest beneficial effect in the treatment of acute bronchitis, with a corresponding small risk of adverse effects. The benefits of antibiotics may be overestimated in this analysis because of the tendency of published reports to include complete data on only the outcomes found to be statistically significant.

Acute Disease↗
PubMed2000

Antibiotics for asymptomatic bacteriuria in pregnancy.

BACKGROUND: Up to 30% of mothers develop acute pyelonephritis if asymptomatic bacteriuria is untreated. Asymptomatic bacteriuria may have a role in preterm birth, or it may be a marker for low socioeconomic status and thus, low birth weight. OBJECTIVES: The objective of this review was to assess the effect of antibiotic treatment for asymptomatic bacteriuria on persistent bacteriuria during pregnancy, the risk of preterm delivery and the development of pyelonephritis after delivery. SEARCH STRATEGY: I searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing antibiotic treatment with placebo or no treatment in pregnant women with asymptomatic bacteriuria found on antenatal screening. DATA COLLECTION AND ANALYSIS: Trial quality was assessed. MAIN RESULTS: Thirteen studies were included. Overall the study quality was not strong. Antibiotic treatment compared to placebo or no treatment was effective in clearing asymptomatic bacteriuria (odds ratio 0.07, 95% confidence interval 0.05 to 0.10). The incidence of pyelonephritis was reduced (odds ratio 0.25, 95% confidence interval 0.19 to 0.32). Antibiotic treatment was also associated with a reduction in the incidence of preterm delivery or low birth weight babies (odds ratio 0.60, 95% confidence interval 0.45 to 0.80). REVIEWER'S CONCLUSIONS: Antibiotic treatment appears to be effective in reducing the risk of pyelonephritis in pregnancy. An apparent reduction in preterm delivery is consistent with current theories about the role of infection in preterm birth, but this association should be interpreted with caution.

Anti-Bacterial Agents↗
PubMed2000

Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures.

BACKGROUND: Many different surgical techniques, such as osteotomy, have been used in internal fixation of extracapsular hip fractures. OBJECTIVES: To compare different aspects of surgical technique in internal fixation of extracapsular hip fractures that have been subjected to randomised trials in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group trials register, Medline, CENTRAL and reference lists of relevant articles were searched. Date of the most recent search: March 1999. SELECTION CRITERIA: All randomised and quasi-randomised trials investigating operative technique for the treatment of extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of an eleven item check list, and extracted data. Wherever possible and appropriate, results of outcome measures were pooled. MAIN RESULTS: All eight included trials were of only modest methodological quality. One trial of 65 patients undergoing fixation with a fixed nail-plate compared osteotomy versus anatomical reduction. There was a tendency to a reduced fixation failure rate after osteotomy. Four trials involving 465 patients undergoing fixation with a sliding hip screw (SHS) compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There was also a tendency to an increased length of hospital stay and limb shortening for osteotomy. One trial of 200 patients undergoing fixation with a SHS compared results with or without compression across the fracture site. The only significant difference in outcomes was increased varus deformity in those fractures treated with compression. One trial of 19 patients reported reduced temperatures generated by a modified method of reaming the femoral head. Another study used oesophageal ultrasound to demonstrate reduced bone marrow intravascular embolism when a Gamma nail was inserted in 50 patients with, rather than without, a distal pressure venting hole in the femur. REVIEWER'S CONCLUSIONS: There is inadequate evidence to determine if any benefits exist for the routine use of osteotomy in conjunction with a SHS for the internal fixation of an unstable trochanteric femoral fracture. Osteotomy may be relevant if used in conjunction with a fixed nail plate. Based on the evidence of one trial only, there is inadequate evidence to support the application of compression across the fracture site of a trochanteric fracture during SHS fixation. Inadequate information exists for different reaming techniques during SHS or Gamma nail fixation to make definite conclusions.

Fracture Fixation, Internal↗
PubMed2000

Corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Acute exacerbations occur quite commonly in patients with chronic obstructive pulmonary disease (COPD). Corticosteroid drugs, either parenteral or oral, are used commonly in this setting. OBJECTIVES: To determine the effect of corticosteroids, administered either parenterally or orally, on the outcome in patients with acute exacerbations of COPD. SEARCH STRATEGY: An initial search was carried out using the Cochrane Airways Group COPD register with additional studies sought in the bibliographies of randomised controlled trials and review articles. Authors of identified randomised controlled trials were contacted for other published and unpublished studies. SELECTION CRITERIA: Randomised controlled trials comparing corticosteroids, administered either parenterally or orally, with appropriate placebo. Other interventions were standardised e.g. bronchodilators, antibiotics. Studies of acute asthma were excluded. DATA COLLECTION AND ANALYSIS: Data was extracted by one reviewer and sent to authors for verification. All trials were combined for analysis where possible. MAIN RESULTS: We identified 7 studies that fulfilled the inclusion criteria. Outcomes were varied and few were common to all studies. The most commonly reported outcome, the FEV1 between 6 - 72 hours after treatment, showed no significant difference between corticosteroid and placebo treatment. Treatment failure (defined as re-attendance in the emergency department, need for oral steroids or hospitalisation) and quality of life did show a statistically significant benefit for corticosteroid treatment, but the number of studies reporting these outcomes was small and there was significant heterogeneity between them REVIEWER'S CONCLUSIONS: Treatment with oral or parenteral corticosteroids in outpatients may decrease the number of patients requiring further treatment or hospitalisation, but otherwise it has no significant effect on the outcome of acute exacerbations of chronic obstructive airways disease. Further research is required to determine the place of corticosteroid treatment in acute exacerbations of chronic obstructive airways disease.

Acute Disease↗
PubMed2000

Newborn screening for cystic fibrosis.

BACKGROUND: This review was performed to test the hypothesis that presymptomatic diagnosis, for example by newborn screening, and early treatment may prevent or reduce irreversible organ damage and thereby improve outcome and quality of life in patients with cystic fibrosis. OBJECTIVES: To determine whether there is evidence that early diagnosis of cystic fibrosis by means of neonatal screening, followed by current treatment, improves survival and long term morbidity, without unacceptable adverse effects. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Trials Register. Additional studies were identified by one of the reviewers from handsearching conference proceedings not included in the Cochrane Register. Pharmaceutical companies manufacturing screening tests for cystic fibrosis were also contacted to identify any trials of neonatal screening for cystic fibrosis. Date of the most recent search of the Group's specialised register: November 1999. SELECTION CRITERIA: All randomised or pseudorandomised controlled trials, published and unpublished, comparing screening followed by early treatment to clinical diagnosis and later treatment in patients with cystic fibrosis. DATA COLLECTION AND ANALYSIS: Four reviewers independently assessed trial eligibility and methodological quality and two of these reviewers independently extracted data. MAIN RESULTS: Two trials involving a total of 1,124,483 neonates met inclusion criteria. A total of 210 patients with cystic fibrosis aged from zero to 11 years with a maximum follow-up of eleven years are included. Concealment of allocation was unclear in both studies. Sequence generation was adequate in one study and unclear in the other. Method to ascertain cases was similar in one study and not similar in the other. An intention-to-screen-analysis was possible in one study, but could not be made due to lack of data and was not performed in the other. Differences in study design, variation in outcomes reported and their summary measures precluded calculation of pooled screening estimates. Only data from one study could be analysed in this review. This study reported a reduced risk of weight and height below the fifth percentile among screened patients (odds ratio control compared with screened group for: weight 6.16, 95% Confidence Interval (CI) 2.44, 15.57 and height 5.03, 95% CI 1. 63, 15.63). Adverse effects among parents in the screened and control populations were examined, but it is difficult to assess how meaningful these results are as the timing of the administration of the questionnaire to each group was not clear. Estimation of direct medical costs of screening suggested it was cheaper to diagnose cystic fibrosis by screening rather than other methods. The costing methods used however were not fully described and costs have not been related to effect. REVIEWER'S CONCLUSIONS: There are few randomised controlled trials assessing the effectiveness of neonatal screening in cystic fibrosis. From the data available at this time, there is little evidence suggesting benefit from screening for cystic fibrosis in the neonatal period, although there is similarly little evidence of harm. This systematic review has identified the need for individual patient data from both included studies. Although we have not been able to perform a meta-analysis, this review provides a summary of all the information currently available from randomised controlled trials on the effectiveness of neonatal screening for cystic fibrosis.

Cystic Fibrosis↗
PubMed2000

Glutamine supplementation for preventing morbidity in preterm infants.

BACKGROUND: The amino acid glutamine is the preferred respiratory fuel for rapidly proliferating cells under normal conditions. Recent research has suggested a number of roles for glutamine during critical illness. This research has been largely performed in experimental animals and in adults in a variety of disease settings. There is little information on the role of glutamine in children and infants, or whether glutamine supplementation is beneficial in preterm babies. OBJECTIVES: To determine the effects of glutamine supplementation on morbidity and weight gain in preterm babies. SEARCH STRATEGY: Searches were made using Medline and Embase electronic databases and specific handsearching in the English language. The search strategy followed the guidelines of the Neonatal Cochrane Review Group. SELECTION CRITERIA: Randomised controlled trials comparing glutamine supplementation to no glutamine supplementation in preterm babies at any time from birth to discharge from hospital. DATA COLLECTION AND ANALYSIS: Data regarding clinical outcomes including duration of parenteral nutrition, time to full enteral nutrition, rate of weight gain, rate of positive blood cultures and duration of hospital stay were extracted by both reviewers. Analysis was performed by the primary reviewer (TRJT) in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS: Three trials met the selection criteria. Data on proportion of babies having one or more of positive blood cultures were available from all three studies. Meta-analysis showed no significant difference between glutamine-supplemented and non-supplemented babies; RR = 0.73 (95% CI 0.44, 1.23), RD = -8.8% (95% CI -23.2, 5.5). Data for other outcome variables were pooled from two studies. There were no significant differences between glutamine-supplemented and non-supplemented babies for days to full enteral nutrition (WMD 0.42, 95% CI -3.0, 3.8), rate of weight gain (WMD 0.6 g/kg/d, 95% CI -1.6, 2.8) or days of hospital stay (WMD -2.4, 95% CI -14.9, 10.2). REVIEWER'S CONCLUSIONS: There is no evidence to support the routine use of parenteral or enteral glutamine supplementation in preterm babies. A large randomised controlled trial should be performed to determine whether or not glutamine supplementation enhances gut integrity and reduces sepsis rate.

Dietary Supplements↗
PubMed2000

Low protein diets delay end-stage renal disease in non diabetic adults with chronic renal failure.

BACKGROUND: Since more than fifty years, low protein diets are proposed to patients with kidney failure. However, the effects of these diets in preventing severe renal failure and the need for maintenance dialysis is still controversial. OBJECTIVES: To determine the efficacy of low protein diets in delaying the need to start maintenance dialysis. SEARCH STRATEGY: Medline and Embase search from January 1966 through June 1999. Congress abstracts (American Society of Nephrology since 1990, European Dialysis Transplant Association since1985, International Society of Nephrology since 1987). Direct contacts with investigators. SELECTION CRITERIA: Randomised trials comparing two different levels of protein intake in adult patients suffering from moderate to severe renal failure, followed for at least one year. Exclusion of patients with diabetic nephropathy. DATA COLLECTION AND ANALYSIS: Seven trials selected over 40 studies since 1975. A total of 1494 patients analysed, 753 receiving a reduced protein intake and 741 a larger protein intake. Collection of the number of "renal death" being the need for starting dialysis, the death of a patient or the transplantation of a kidney during the trials. MAIN RESULTS: 242 renal deaths were recorded, 101 in the low protein diet and 141 in the larger protein diet group, giving an odds ratio of low protein to control of 0.62 with a 95% confidence interval of 0.46 to 0.83 (p<0.001, Peto odds ratio). To spare one extra renal death, 17 patients need to be treated (NNT) with a low protein diet for approximately two years. REVIEWER'S CONCLUSIONS: Reducing protein intake in patients with chronic renal failure do reduce the occurence of renal death by about 40% as compared with larger or unrestricted protein intake and therefore should be warmly recommended to patients. The optimal level of protein intake cannot be deduced from the present work. However, based on other nutritional studies perfomed in patients having chronic renal failure, we recommend a protein intake of 0.6 g/kg/day and an energy intake no less than 35 kcal/kg/day. Skilled dietitian survey should be offered to closely monitor these values and the patient's nutritional status.

Adult↗
PubMed2004

Value of updating a systematic review in surgery using individual patient data.

BACKGROUND: Previous research has highlighted the advantages of individual patient data (IPD) meta-analyses. However, they are resource intensive and take considerable time to complete. The aim of this study was to determine whether the extra investment is justified by greater accuracy or usefulness by means of a case study in surgery. METHODS: An updated review using IPD, where possible, was compared with an earlier version based on aggregate published data to determine whether there were statistically significant changes in estimates of effectiveness for hernia recurrence and persisting pain. Differences related to the type of laparoscopic repair, the type of open repair and methodological quality were also explored. RESULTS: The results for hernia recurrence changed little. However, the IPD update led to divergent conclusions for persisting pain. The published data implied a statistically significant benefit in favour of open repair, whereas the IPD result implied a statistically significant benefit in favour of laparoscopic repair (P < 0.001). Methodological quality did not account for this difference. CONCLUSION: Updating of systematic reviews using IPD can be conducted successfully in surgery. This example led to little change in estimates of effectiveness for hernia recurrence but yielded qualitatively different estimates for persisting pain, an outcome rarely included in the published reports.

Humans↗
PubMed2003

How objective are systematic reviews? Differences between reviews on complementary medicine.

Systematic reviews are considered the most reliable tool to summarize existing evidence. To determine whether reviews that address the same questions can produce different answers we examined systematic reviews of herbal medicine, homeopathy, and acupuncture taken from a previously established database. Information on literature searching, inclusion criteria, selection process, quality assessment, data extraction, methods to summarize primary studies, number of included studies, results and conclusions was compared qualitatively. Seventeen topics (eight on acupuncture, six on herbal medicines, three on homeopathy) had been addressed by 2-5 systematic reviews each. The number of primary studies in the reviews varied greatly within most topics. The most obvious reason for discrepancies between the samples was different inclusion criteria (in thirteen topics). Methods of literature searching may have contributed with some topics but the equivalence of the searches was difficult to assess. Differences were frequently observed in other methodological aspects, in results and in conclusions. This analysis shows that, at least in the three areas examined, systematic reviews often differ considerably. Readers should be aware that apparently minor decisions in the review process can have major impact.

Clinical Trials as Topic↗