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PubMed2000

Combined inhaled anticholinergic agents and beta-2-agonists for initial treatment of acute asthma in children.

BACKGROUND: Anti-cholinergic agents and beta2-agonist drugs are both bronchodilators used to reverse acute bronchospasm in children with asthma. These drugs have different modes of action, so may have complementary or additive effects. OBJECTIVES: The objective of this review was to assess the effects of adding inhaled anti-cholinergics to beta2-agonists in acute paediatric asthma. SEARCH STRATEGY: We searched Medline (1966 to 1996), Embase (1980 to 1995), Cinahl (1982 to 1995) and reference lists of studies. We also contacted drug manufacturers and researchers. SELECTION CRITERIA: Randomised trials comparing the combination of inhaled anti-cholinergics and beta2-agonists with beta2-agonists alone in children aged 18 months to 17 years with acute asthma. DATA COLLECTION AND ANALYSIS: Assessments of trial quality and data extraction were done by two reviewers independently. MAIN RESULTS: Ten trials involving a total of 836 children were included. Most trials were of high quality. When only one dose of anti-cholinergic inhalation was added to beta2-agonist therapy, there was an improvement in forced expiratory volume in one second after 60 minutes with combination therapy (weighted mean difference 16.1%, 95% confidence interval 5.5 to 26. 7% reduction). There was no reduction in hospital admission (odds ratio 0.80, 95% confidence interval 0.35 to 1.82, using a random effects model). For multiple doses in children with severe asthma, there was a reduction in forced expiratory volume in 1 second (weighted mean difference 9.8% predicted, 95% confidence interval 6. 5 to 13.1% predicted). There may also be a reduction in hospital admission (odds ratio 0.62, 95% confidence interval 0.38 to 0.99). Eleven children would need to be given multiple doses of anti-cholinergics in combination with beta2-agonists to avoid one hospital admission compared to children given beta2-agonists alone. REVIEWER'S CONCLUSIONS: In children with acute asthma, the addition of multiple doses of anti-cholinergics to inhaled beta2-agonists appears to improve lung function modestly and may decrease hospital admission. There is no associated increase in adverse effects. Single doses of anti-cholinergics may improve lung function in children with severe asthma, but do not appear to reduce hospital admissions.

Administration, Inhalation↗
PubMed2000

Growth hormone for in vitro fertilization.

BACKGROUND: Ovulation induction protocols for in vitro fertilization (IVF) are constantly under review and revision in an attempt to decrease gonadotropin requirements while improving follicular recruitment and pregnancy rate. Most studies of the effect of Growth Hormone on ovulation induction have investigated normally ovulating infertile women. Attention has begun to turn to its effect on women who fail to produce an optimal number of follicles in response to ovulation induction. OBJECTIVES: To assess the effectiveness of growth hormone adjuvant therapy for women undergoing ovulation induction prior to IVF in two patient groups: a) those with no previous history of poor response and b) those with a history of poor response. SEARCH STRATEGY: This review has drawn on the search strategy developed for the Subfertility Group as a whole. Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group details for more information. SELECTION CRITERIA: All RCTs were included if they addressed the research question posed and provided outcome data for intervention and control subjects. Outcomes of interest included pregnancy, oocyte/embryo number and peak estradiol level. DATA COLLECTION AND ANALYSIS DATA EXTRACTION: A diverse search strategy was employed, including hand-search of 43 core journals from 1966 to the present, bibliographies of relevant trials, MEDLINE database, abstracts from North American and European meetings and contact with authors of relevant papers. Relevant data were extracted independently by two reviewers using the standardized data extraction sheet. Validity was assessed in terms of method of randomization, completeness of follow-up, presence or absence of crossover and co-intervention. DATA SYNTHESIS: 2x2 tables were generated for all relevant outcomes. Odds ratios were generated using the Peto modified Mantel-Haenszel technique. Statistical heterogeneity was assessed using x2. MAIN RESULTS: In women with no previous history of poor stimulation, the common odds ratio for pregnancy per cycle was 0.97 (95% CI 0.34-2. 76) Total dose of gonadotropin and number of oocytes retrieved were similar between treated and placebo groups. In previous poor responders, the common odds ratio for pregnancy per cycle instituted was 2.55 (95% CI 0.64-10.12). Again, no statistically significant difference was noted in gonadotropin dosage or oocyte number obtained, when all studies were considered. REVIEWER'S CONCLUSIONS: Data from 6 small trials suggest that in women with no previous poor response, GH augmentation does not improve the rate of pregnancy. In poor responders, a trend towards improved outcome with GH treatment deserves further study.

Female↗
PubMed2000

Ovulation suppression for endometriosis.

BACKGROUND: Although the etiology of endometriosis is unknown, several theories exist, the most popular of which is retrograde menstruation. As endometriosis can only be diagnosed by laparoscopy, neither the incidence (annual occurrence) nor the prevalence (proportion of the population affected) of endometriosis is known. The association between endometriosis and infertility isn't clear in Stage I (minimal) and Stage II (mild) endometriosis. Endometriosis appears to be an estrogen dependent condition. At the time of menopause, most endometriosis becomes quiescent. This hormonal dependency prompted researchers to seek agents which would suppress ovarian activity. OBJECTIVES: To determine effectiveness of a) ovulation suppression with danazol, medroxy progesterone acetate, gestrinone, combined oral contraceptive pills and GnRH analogues versus placebo or no treatment and b) any of the above agents versus danazol, for the treatment of endometriosis explained infertility in terms of clinical pregnancy rate. SEARCH STRATEGY: The Cochrane Subfertility Review Group specialised register of controlled trials was searched. SELECTION CRITERIA: Four RCTs with five treatment arms compared an ovulation suppression agent with placebo or no treatment. Eight trials were identified comparing a suppressive agent with danazol. DATA COLLECTION AND ANALYSIS DATA EXTRACTION: A diverse search strategy was employed, including hand-search of 43 core journals from 1966 to the present, bibliographies of relevant trials, MEDLINE database, abstracts from North American and European meetings and contact with authors of relevant papers. Relevant data were extracted independently by two reviewers using the standardised data extraction sheet. Validity was assessed in terms of method of randomisation, completeness of follow-up, presence or absence of crossover and co-intervention. DATA SYNTHESIS: 2x2 tables were generated for all relevant outcomes. Odds ratios were generated using the Peto modified Mantel-Haenszel technique. Statistical heterogeneity was assessed using x2. MAIN RESULTS: The common odds ratio for pregnancy following ovulation suppression versus placebo or no treatment was 0.83 (95% CI 0.5-1.39). These data were statistically homogeneous although clinical heterogeneity was present. Their consistency in showing no treatment benefit suggests that this group of interventions is ineffective. Common odds ratio for pregnancy following all agents versus danazol was 1.20 (95% CI 0. 85-1.68). Again these data were homogeneous and suggest no significant treatment benefit in terms of pregnancy rate. REVIEWER'S CONCLUSIONS: Given the significant period of amenorrhea associated with ovulation suppression, the lack of treatment benefit demonstrated and the adverse effects commonly associated with these treatments, ovulation suppression cannot be recommended as a standard therapy for endometriosis-associated infertility.

Danazol↗
PubMed2000

Prostaglandins for prevention of postpartum haemorrhage.

BACKGROUND: Prostaglandins have mainly been used for postpartum haemorrhage when other measures fail. Misoprostol, a newer and cheaper prostaglandin E1 analogue, has sometimes been used for management of the third stage of labour. OBJECTIVES: The objective of this review was to assess the effects of prophylactic prostaglandin use in the third stage of labour. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Researchers in the field were also contacted. Date of the latest search: December 1999. SELECTION CRITERIA: Randomized or quasi-randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality was assessed by one reviewer. MAIN RESULTS: Seven trials were included. There were six trials of injectable prostaglandins and one of rectal misoprostol. The main limitations of these studies are their small sample sizes and lack of blind assessment of the outcomes. Injectable prostaglandins were associated with decreased blood loss (weighted mean difference -72 millilitres, 95% confidence interval -70 to -75) and shortened duration of third stage when compared to other uterotonics. Severe postpartum haemorrhage (1000 millilitres or more blood loss) occurred in two of four studies and was seen in fewer women receiving prostaglandins, though the difference was not statistically significant. Adverse effects (vomiting, diarrhoea and abdominal pain) were more common with prostaglandins when compared to other uterotonic agents. REVIEWER'S CONCLUSIONS: Although injectable prostaglandins appear to be effective in preventing postpartum haemorrhage, concerns about safety and costs limit their suitability for routine prophylactic management of third stage of labour. However, injectable prostaglandins should continue to be used for the treatment of postpartum haemorrhage when other measures fail. Misoprostol is cheap, stable and seems to be safe. Trials addressing the effectiveness of misoprostol are continuing.

Female↗
PubMed2000

Laparoscopic "drilling" by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome.

BACKGROUND: Problems in inducing ovulation in women with polycystic ovary syndrome (PCOS) and anovulation (failure to ovulate) are well recognised. Surgical ovarian wedge resection was the first established treatment for anovulatory PCOS patients but was largely abandoned of the risk of post-surgical adhesion formation. It was replaced by medical ovulation induction with clomiphene and gonadotrophins. However patients with PCOS treated with gonadotrophins often have a polyfollicular response and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Although effective, it is an expensive, stressful and time consuming form of treatment requiring intensive monitoring. A new surgical therapy, laparoscopic ovarian "drilling", may avoid or reduce the need, or facilitate the use, of gonadotrophins for inducing ovulation. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions. It has been claimed in many uncontrolled observational studies that it is followed, at least temporarily, by a high rate of spontaneous postoperative ovulation and conception, or that subsequent medical ovulation induction becomes easier. OBJECTIVES: To determine the effectiveness of laparoscopic ovarian drilling for ovulation induction in subfertile women with anovulation (failure to ovulate) and polycystic ovarian syndrome (PCOS). SEARCH STRATEGY: The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of randomised controlled trials (RCTS). A computerised MEDLINE search was used to identify non randomised controlled trials. SELECTION CRITERIA: Trials were eligible for inclusion if treatment consisted of laparoscopic ovarian drilling in order to induce ovulation in subfertile women with PCOS and compared with a concurrent control group. DATA COLLECTION AND ANALYSIS: Fourteen trials were identified; eight were included in the review of which seven were randomised. All trials were assessed for quality criteria. The main studied outcomes were ovulation and pregnancy rates. Miscarriage rate, multiple pregnancy rate, and incidence of overstimulation and ovarian hyperstimulation syndrome rate were secondary outcomes. MAIN RESULTS: With the exception of multiple pregnancy rates no differences were demonstrated for any of the interventions studied but the numbers of patients who have been randomised to controlled studies at this time is insufficient to conclude that laparoscopic ovarian drilling is more effective than gonadotrophin therapy for other outcomes. REVIEWER'S CONCLUSIONS: The value of laparoscopic ovarian drilling as a primary treatment for subfertile patients with anovulation (failure to ovulate) and polycystic ovarian syndrome (PCOS) is undetermined. There is insufficient evidence to determine a difference in ovulation or pregnancy rates when compared to gonadotrophin therapy as a secondary treatment for clomiphene resistant women. Multiple pregnancy rates are reduced in those women who conceive following laparoscopic drilling. None of the studied modalities of drilling technique had any obvious advantages.

Anovulation↗
PubMed2000

Antibiotic prophylaxis for intrauterine contraceptive device insertion.

BACKGROUND: Concern about the risk of upper genital tract infection (pelvic inflammatory disease) often limits use of the IUD, a highly effective contraceptive. Prophylactic antibiotic administration around the time of induced abortion significantly reduces the risk of postoperative endometritis.(Sawaya, 1996) Since the risk of IUD-related infection is limited to the first few weeks to months after insertion,(Lee, 1983; Farley, 1992) contamination of the endometrial cavity at the time of insertion(Mishell, 1966) appears to be the mechanism, rather than the IUD or string itself. Thus, antibiotic administration before IUD insertion might reduce the risk of upper genital tract infection from passive introduction of bacteria at insertion. OBJECTIVES: To assess the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing IUD-related complications and discontinuations within three months of insertion. The primary outcome was pelvic inflammatory disease (four reports) or early removals of the device (two reports). SEARCH STRATEGY: We searched both MEDLINE and EMBASE, handsearches of journals through CENTRAL, and lists of references. We also wrote to international experts in the field to identify unpublished studies. SELECTION CRITERIA: We included randomized controlled trials using any antibiotic compared with a placebo. We found four such trials; two had pilot study data available. DATA COLLECTION AND ANALYSIS DATA EXTRACTION: We used searches of MEDLINE, EMBASE, and handsearches of journals available through CENTRAL. We also reviewed lists of references in original research and in review articles. We wrote to experts to identify unpublished trials and made telephone calls to authors to supply missing information. Two independent reviewers abstracted data. We assessed the validity of each study using methods suggested in the Cochrane Handbook. DATA SYNTHESIS: We generated 2x2 tables for the principal outcome measures. We used the Peto modified Mantel-Haenszel technique to calculate odds ratios and assessed statistical heterogeneity between studies. MAIN RESULTS: The odds ratios for pelvic inflammatory disease associated with use of prophylactic doxycycline or azithromycin compared with placebo or no treatment was 0.89 (95%CI 0.53-1.51). Use of prophylaxis was associated with a small reduction in unscheduled vists to the provider (OR 0.82; 95% CI 0.70-0.98). Use of doxycycline or azithromycin had little effect on the likelihood of removal of the IUD within 90 days of insertion (OR 1.05; 95% CI 0.68-1.63). Significant heterogeneity did not exist between studies. REVIEWER'S CONCLUSIONS: Use of either doxycycline 200 mg or azithromycin 500 mg by mouth before IUD insertion confers little benefit. While the reduction in unscheduled visits to the provider was marginally significant, the cost-effectiveness of routine prophylaxis remains questionable. A uniform finding in these trials was the low risk of IUD-associated infection, with or without use of antibiotic prophylaxis.

Antibiotic Prophylaxis↗
PubMed2000

Nicotine for Alzheimer's disease.

BACKGROUND: Nicotine is a cholinergic agonist that acts, not only post-synaptically, but also releases pre-synaptic acetylcholine, and in animal models has been shown to reverse spatial memory decline in rats with lesion in the medial septal nucleus and to show recovery on memory in aged monkeys. Nicotine also has effects on other transmitters like serotonin (5HT), dopamine, or GABA. On the other hand, because nicotine has serious adverse effects, especially concerning cardiovascular risks in elderly people, and also on sleep and behavior, there are several important reasons to conduct a systematic review to assess the clinical efficacy and safety of nicotine in patients with AD. OBJECTIVES: The aim of this review is to determine whether there is evidence of beneficial effect, and to assess its safety profile, when nicotine is used for Alzheimer's disease. SEARCH STRATEGY: The Cochrane Controlled Trials Register (Issue 2, 99) was searched using the terms nicotin* and alzheimer*. Three references to trials were deemed suitable for inclusion but are awaiting consideration while the investigators are contacted. SELECTION CRITERIA: All unconfounded, double-blind, randomized trials in which treatment with nicotine patches or administration of nicotine intravenously was administered for more than a day and compared to placebo in people with Alzheimer's disease. DATA COLLECTION AND ANALYSIS: As no trials were suitable for inclusion, no data have been extracted or pooled in a meta-analysis. One trial is awaiting consideration, and if included in an update of this review, any available data will be incorporated. MAIN RESULTS: The poor quality of the trials did not allow any synthesis of results across studies. However, the data available in trials considered are compatible with nicotine producing harm, no change or improvement. REVIEWER'S CONCLUSIONS: This review is not able to provide reliable evidence that nicotine is a useful treatment for Alzheimer's disease.

Alzheimer Disease↗
PubMed2000

Antimalarials for rheumatoid arthritis.

OBJECTIVES: To estimate the short-term efficacy and toxicity of antimalarials for the treatment of rheumatoid arthritis (RA). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register, Medline and Embase up to and including July 1997. We also carried out a handsearch of the reference lists of the trials retrieved from the electronic search. SELECTION CRITERIA: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing antimalarials against placebo in patients with RA DATA COLLECTION AND ANALYSIS: Data abstraction was carried out independently by two reviewers. The same two reviewers using Jadad's scale (Jadad 1995) assessed the methodological quality of the RCTs and CCTs. Rheumatoid arthritis outcome measures were extracted from the publications for the 6-month endpoint. The pooled analysis was performed using standardized mean differences for joint counts, pain and global assessments. Weighted mean differences were used for erythrocyte sedimentation rate (ESR). Toxicity was evaluated with pooled odds ratios for withdrawals. A chi-square test was used to assess heterogeneity among trials. Fixed effects models were used throughout. MAIN RESULTS: We found four trials, with 300 patients randomized to hydrochloroquine and 292 to placebo. Only trials evaluating hydroxychloroquine could be pooled in the analysis. A statistically significant benefit was observed when hydroxychloroquine was compared to placebo. The standardized mean differences for the various outcome measures ranged from -0.33 to -0. 52, and were statistically significant. Statistically significant differences were also observed for ESR. Overall withdrawals and withdrawals due to lack of efficacy were significantly more frequent in the placebo group. No differences were observed in withdrawals due to toxicity. REVIEWER'S CONCLUSIONS: Hydroxychloroquine appears to be efficacious for the treatment of RA. Its overall effect appears to be moderate, but its low toxicity profile should be considered when treating patients with RA.

Antimalarials↗
PubMed2000

Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND).

BACKGROUND: Riluzole has been approved for treatment of patients with amyotrophic lateral sclerosis (ALS) in some countries but not others. Questions persist about its clinical utility because of high cost, modest efficacy and concern over adverse effects. OBJECTIVES: To examine the efficacy of riluzole in prolonging survival, and in delaying the use of surrogates (tracheostomy and mechanical ventilation) to sustain survival. SEARCH STRATEGY: Search of the Cochrane Neuromuscular Disease Group Register for randomized trials and enquiry from authors of trials and other experts in the field. The most recent search was conducted in June 1999. SELECTION CRITERIA: Types of studies: randomized trials TYPES OF PARTICIPANTS: adults with a diagnosis of ALS Types of interventions: treatment with riluzole or placebo Types of outcome measures: Primary: per cent mortality at 12 months with riluzole 100 mg Secondary: per cent mortality as a function of time with 100 mg and with all doses of riluzole, scales of neurologic function, quality of life, muscle strength and adverse events. DATA COLLECTION AND ANALYSIS: We identified two randomized trials. Each reviewer graded them for methodological quality. Data extraction was performed by a single reviewer and checked by the other two. We obtained some missing data from investigators. We performed meta-analyses with RevMan software using a fixed effects model. MAIN RESULTS: The two eligible trials included a total of 794 riluzole treated patients and 320 placebo treated patients. The methodological quality was acceptable and the trials were easily comparable. There were significant differences between the riluzole and placebo groups of both trials, in terms of the primary outcome measure, which was per cent mortality at 12 months with the 100 mg dose of riluzole. The odds ratio for the combined studies was 0.57 (95%CI 0.41 to 0.80) at 12 months. In the secondary outcome measures, there was a survival advantage with riluzole 100 mg at six, nine, 12 and 15 months, but not at three or 18 months. Pooled data from the 50, 100 and 200mg dose groups in the larger trial showed a lower per cent mortality with riluzole compared to placebo only at 12 months (odds ratio (OR) 0.64, 95% CI 0.47 to 0.88). There was no beneficial effect on bulbar function, or muscle strength. There were scant data on quality of life, but patients treated with riluzole remained in a more moderately affected health state significantly longer than placebo-treated patients (weighted mean difference (WMD) 35.5 days, 95% CI 5.9 to 65. 0). A threefold increase in serum alanine transferase was more frequent in riluzole treated patients than controls (WMD 2.65, 95% CI 1.51 to 4.65). REVIEWER'S CONCLUSIONS: Riluzole 100 mg per day appears to be modestly effective in prolonging survival for patients with ALS.

Amyotrophic Lateral Sclerosis↗
PubMed2000

Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne.

BACKGROUND: Hirsutism is the presence of excessive hair growth in women and is an important cosmetic condition often resulting in severe distress. Hirsutism is most often caused by increased production of male sex hormones also known as androgens. It is also affected by increased sensitivity to androgens in the hair follicles, and the secretory glands around the hair follicles, called sebaceous glands. Spironolactone is an antiandrogen and aldosterone antagonist used to treat hirsutism. Since 1978, many studies have been conducted to determine its effectiveness. OBJECTIVES: The objective of this review was to investigate the effectiveness of spironolactone and/or in combination with steroids (oral contraceptive pill included) in reducing excess hair growth and/or acne in women. SEARCH STRATEGY: All publications of randomised controlled trials of spironolactone versus placebo and/or in combination with steroids (oral contraceptive pill included) were identified. Search strategy was developed by the Menstrual Disorder Group. All accessable electronic databases were searched. In addition, all reference lists of relevant trials were searched and drug companies contacted for details of unpublished trials. SELECTION CRITERIA: All randomised controlled comparisons of spironolactone versus: placebo steroids (oral contraceptive pill included)) spironolactone of varying dosages or spironolactone and steroids versus steroids alone when used to reduce hair growth and acne in women. DATA COLLECTION AND ANALYSIS: Four trials were included in the review, seven trials were excluded. Two other trials are awaiting assessment. All included trials were small (no more than 31 participants) randomised and controlled. Only one trial studied acne as an outcome, the remaining three were concerned with hirsutism. One trial investigated spironolactone versus placebo; one trial was a dosage studies of spironolactone; one trial compared spironolactone with spironolactone in combination with dexamethasone; the remaining trial used topical spironolactone for the treatment of acne. Major outcome measures include the following: - subjective observations - Ferriman and Gallwey hair scores - hormonal and biochemical parameters - side effects - sebum production measurement MAIN RESULTS: All sample populations were small and confidence intervals were wide. There was no significant difference between treatments for any of the observed outcomes. REVIEWER'S CONCLUSIONS: The effectiveness of treatment for either acne vulgaris or hirsutism cannot be determined due to the small sample populations involved in the trials. Its value in clinical practice is difficult to assess from currently available research.

Acne Vulgaris↗
PubMed2000

Psychoeducation for schizophrenia.

BACKGROUND: Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' awareness of their illness and its treatment. OBJECTIVES: To assess the effects of psychoeducational interventions compared to standard levels of knowledge provision. SEARCH STRATEGY: Electronic searches of CINAHL (1982-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMbase (1980-1999), MEDLINE (1966-1999), PsycLit (1974-1999), and Sociofile (1974-1999) were undertaken. These were supplemented with reference searching and personal contact with authors of all included studies. SELECTION CRITERIA: All relevant randomised controlled trials focusing on psychoeducation for schizophrenia or related serious mental illnesses, involving individuals or groups. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted independently by at least two reviewers from included papers. Authors of trials were contacted for additional and missing data. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Where possible the numbers needed to treat (NNT) were also calculated. Weighted or standardised means were calculated for continuous data. MAIN RESULTS: Ten studies are included in this review. All studies of group education included family members. Compliance with medication was significantly improved in a single study using brief group intervention (at one year) but other studies produced equivocal or skewed data. Any kind of psychoeducational intervention significantly decreased relapse or readmission rates at nine to 18 months follow-up compared with standard care (RR 0.8 CI 0.7-0.9 NNT 9 CI 6-22). Several of the secondary outcomes (knowledge gains, mental state, global level of functioning, status of high expressed emotion family members) were measured using scales that are difficult to interpret. Generally, however, findings were consistent with the possibility that psychoeducation has a positive effect on a persons' well being. No impact was found on insight, medication related attitudes or on overall satisfaction with services of patients or relatives but these findings rested on very few studies. Health economic outcome was only measured in one study and data were skewed. It was not possible to analyse whether different duration or formats of psychoeducation influenced effectiveness. REVIEWER'S CONCLUSIONS: Evidence from trials suggests that psychoeducational approaches are useful as a part of the treatment programme for people with schizophrenia and related illness. That the interventions are brief and inexpensive should make them attractive to managers and policy makers. More well-designed, conducted and reported randomised studies investigating the efficacy of psychoeducation are needed.

Family↗
PubMed2006

Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials.

OBJECTIVE: To evaluate the clinical efficacy of topical 20% azelaic acid cream and 15% azelaic acid gel compared with their respective vehicles and metronidazole gel in the treatment of papulopustular rosacea. DATA SOURCES: Electronic searches of MEDLINE, EMBASE, BIOSIS, and SciSearch through July or August 2004 and the Cochrane Central Register of Controlled Trials through 2004 (issue 3). We performed hand searches of reference lists, conference proceedings, and clinical trial databases. Experts in rosacea and azelaic acid were contacted. STUDY SELECTION: Randomized controlled trials involving topical azelaic acid (cream or gel) for the treatment of rosacea compared with placebo or other topical treatments. Two authors independently examined the studies identified by the searches. Ten studies were identified, of which 5 were included (873 patients). DATA EXTRACTION: Two authors independently extracted data from the included studies, then jointly assessed methodological quality using a quality assessment scale. DATA SYNTHESIS: Because standard deviation data were not available for 4 of the 5 studies, a meta-analysis could not be conducted. Four of the 5 studies demonstrated significant decreases in mean inflammatory lesion count and erythema severity after treatment with azelaic acid compared with vehicle. None of the studies showed any significant decrease in telangiectasia severity. CONCLUSIONS: Azelaic acid in 20% cream and 15% gel formulations appears to be effective in the treatment of papulopustular rosacea, particularly in regard to decreases in mean inflammatory lesion count and erythema severity. Compared with metronidazole, azelaic acid appears to be an equally effective, if not better, treatment option.

Administration, Cutaneous↗
PubMed2000

Maternal oxygen administration for suspected impaired fetal growth.

BACKGROUND: Fetal hypoxaemia is often a feature of fetal growth impairment. It has been suggested that perinatal outcome after suspected impaired fetal growth might be improved by giving mothers continuous oxygen until delivery. OBJECTIVES: The objective was to assess the effects of maternal oxygen therapy in suspected impaired fetal growth on fetal growth and perinatal outcome. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. SELECTION CRITERIA: Acceptably controlled trials comparing maternal oxygen therapy with no oxygen therapy in suspected impaired fetal growth. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality was assessed. MAIN RESULTS: Two studies involving 62 women were included. Oxygenation compared with no oxygenation was associated with a lower perinatal mortality rate (relative risk 0.41, 95% confidence interval 0.21 to 0.78). However higher gestational age in the oxygenation groups may have accounted for the difference in mortality rates. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the benefits and risks of maternal oxygen therapy for suspected impaired fetal growth.

Female↗
PubMed2000

Cholinergic medication for neuroleptic-induced tardive dyskinesia.

BACKGROUND: Since the 1950's neuroleptic medication has been extensively used to treat people with chronic mental illnesses, such as schizophrenia. These may cause tardive dyskinesia (TD), abnormal, repetitive and involuntary movements, in up to 20% of those using the medication for longer than three months. One theory of causation supports the use of cholinergic drugs for the management of TD. OBJECTIVES: To determine whether the use of cholinergic agents (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86) were associated with clinical improvement in neuroleptic-induced TD in people with schizophrenia or other chronic mental illnesses. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1995), Cochrane Schizophrenia Group's Register of trials (1995), EMBASE (1980-1995), LILACS (1982-1996), MEDLINE (1966-1995), PsycLIT (1974-1995), and SCISEARCH (1995) were undertaken. References of all identified studies were searched for further trial citations. Principal authors of trials were contacted. SELECTION CRITERIA: Reports identified in the search were included if they were controlled trials dealing with people with neuroleptic-induced TD and schizophrenia or other chronic mental illnesses who had been randomly allocated to either a cholinergic agent or to a placebo (or no intervention). DATA COLLECTION AND ANALYSIS: Seven different studies (8 references) were included in this review, and another ten trials are currently awaiting further data from authors. Data were independently extracted from these trials by each reviewer and odds ratios (OR) or average differences, with the 95% confidence intervals (95% CI) were estimated. The reviewers assumed that people who dropped out had no improvement. MAIN RESULTS: The studies failed to detect any significant advantage of deanol or lecithin when compared to placebo. Data from two deanol trials demonstrated an excess of side effects in the active treatment group. People on cholinergic compounds report a range of gastrointestinal adverse effects (anorexia, nausea, vomiting, diarrhea, abdominal pain), sedation, and undesirable body odour. One person died of acute aspiration in a deanol versus placebo cross-over study. REVIEWER'S CONCLUSIONS: This review provides no strong evidence for the use of cholinergic agents in the treatment of neuroleptic-induced tardive dyskinesia. While people receiving cholinergic treatment had a marginal benefit compared to placebo, because of the small sample size, the cumulative data must be interpreted as inconclusive. Clinicians and trialists considering using cholinergic agents to treat TD should balance the lack of evidence for the efficacy against the excess of side effects associated with these compounds.

Antipsychotic Agents↗
PubMed2000

Intravenous immunoglobulin for preventing infection in preterm and/or low-birth-weight infants.

BACKGROUND: Nosocomial infections continue to be a significant cause of morbidity and mortality among preterm and/or low birth weight infants. Maternal transport of immunoglobulins to the fetus mainly occurs after 32 weeks gestation and endogenous synthesis does not begin until several months after birth. Administration of intravenous immunoglobulin provides IgG that can bind to cell surface receptors, provide opsonic activity, activate complement, promote antibody dependent cytotoxicity, and improve neutrophilic chemoluminescence. Intravenous immunoglobulin thus has the potential of preventing or altering the course of nosocomial infections. OBJECTIVES: To assess the effectiveness/safety of intravenous immunoglobulin (IVIG) administration (compared to placebo or no intervention) to preterm (< 37 weeks gestational age at birth) and/or low birth weight (LBW) (< 2500 g BW) infants in preventing nosocomial infections. SEARCH STRATEGY: Medline, Embase, Cochrane Library and Reference Update Databases were searched in November 1997 using keywords: immunoglobulin and infant-newborn and random allocation or controlled trial or randomized controlled trial (RCT). The reference lists of identified RCTs, personal files and Science Citation Index were searched. No language restrictions were applied. SELECTION CRITERIA: The criteria used to select studies for inclusion in this overview were: 1) DESIGN: RCTs in which administration of IVIG was compared to a control group that received a placebo or no intervention. 2) POPULATION: preterm (< 37 weeks gestational age) and/or LBW (<2500 g) infants. 3) INTERVENTION: IVIG for the prevention of bacterial/fungal infection during initial hospital stay (8 days or longer). (Studies that were primarily designed to assess the effect of IVIG on humoral immune markers were excluded as were studies in which the follow-up period was one week or less). 4) At least one of the following outcomes was reported: sepsis, any serious infection, death from all causes, death from infection, length of hospital stay, intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD). DATA COLLECTION AND ANALYSIS: Two reviewers independently abstracted information for each outcome reported in each study, and one researcher (AO) checked for any discrepancies and pooled the results. Relative risk (RR) and Risk Difference (RD) with 95% confidence intervals (CI) using the fixed effects model are reported. When a statistically significant RD was found the number needed to treat (NNT) was also calculated with 95% CIs. The results include all accepted studies in which the outcome of interest was reported. When statistically significant heterogeneity was found for an outcome, secondary (sensitivity) analyses were performed including only studies of the highest quality. MAIN RESULTS: Fifteen studies met inclusion criteria. These included 5,054 preterm and/or LBW infants and reported on at least one of the outcomes of interest for this systematic review. When all studies were combined there was a statistically significant reduction in sepsis, one or more episodes [RR 0.83 (95% CI 0.72, 0.97); RD -0.028 (95% CI -0.006, -0.051); NNT 36 (95% CI 20, 167)]. There was significant between-study heterogeneity. When, in a sensitivity analysis, the high quality studies were combined, the results remained significant [RR 0.78 (95% CI 0.62, 0.98); RD -0.031(95% CI -0.003, -0.059); NNT 32 (95% CI 17, 333]. For this analysis there was no statistically significant between-study heterogeneity. A statistically significant reduction was also found for any serious infection, one or more episodes, when all studies were combined [RR 0.85 (95% CI 0.75, 0. 95); RD -0.032 (95% CI -0.010, -0.054,); NNT 31 (95% CI 19, 100). There was statistically significant between-study heterogeneity. When, in a sensitivity analysis, the high quality studies were combined the results remained statistically significant [RR 0.80 (95% CI

Cross Infection↗
PubMed2000

Vaccines for preventing influenza in people with asthma.

BACKGROUND: Influenza vaccination is recommended for asthmatic patients in many countries as observational studies have shown that influenza infection can be associated with asthma exacerbations, but influenza vaccination itself has the potential to adversely affect pulmonary function. A recent overview concluded that there was no clear benefit of influenza vaccination in patients with asthma but this conclusions was not based on a systematic search of the literature. OBJECTIVES: Whilst influenza may cause asthma exacerbations, there is controversy about the use of influenza vaccinations, since they may precipitate an asthma attack in some people. The objective of this review was to assess the effects of influenza vaccination in children and adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and checked reference lists of articles. SELECTION CRITERIA: Randomised trials of influenza vaccination in children (over two years of age) and adults with asthma. Studies involving people with chronic obstructive pulmonary disease were excluded. DATA COLLECTION AND ANALYSIS: Inclusion criteria and assessment of trial quality were applied by two reviewers independently. Data extraction was done by two reviewers independently. Study authors were contacted for missing information. MAIN RESULTS: Nine trials were included. Four of these trials were of high quality. One further article has been included since the previous version of this review. Inclusion of the new trial has not altered the conclusions of this review. The included studies covered a wide diversity of people, settings and types of influenza vaccination, so data from the different trials were not pooled. In one trial, no protective effect of influenza vaccination against asthma exacerbation was demonstrated, but the incidence of influenza was low during the study period. A higher number of asthma exacerbations following killed influenza vaccination was found in one trial (risk difference 3 1%, 95% confidence interval 0.3% to 5.8%). When people with upper respiratory tract infections were excluded, this difference was no longer significant. A small trial using recombinant vaccine found no significant difference in asthma exacerbations between the vaccinated and placebo groups. REVIEWER'S CONCLUSIONS: There is not enough evidence to assess the benefits and risks of influenza vaccination for people with asthma.

Adult↗
PubMed2000

Gastro-oesophageal reflux treatment for asthma in adults and children.

BACKGROUND: Asthma and gastro-oesophageal reflux are both common medical conditions and often co-exist. Studies have shown conflicting results concerning the effects of lower oesophageal acidification as a trigger of asthma. Furthermore, asthma might precipitate gastro-oesophageal reflux. Thus a temporal association between the two does not establish that gastro-oesophageal reflux triggers asthma. Randomised trials of a number of treatments for gastro-oesophageal reflux in asthma have been conducted, with conflicting results. OBJECTIVES: The objective of this review was to evaluate the effectiveness of treatments for gastro-oesophageal reflux in terms of their benefit on asthma. SEARCH STRATEGY: The Cochrane Airways Group trials register, review articles and reference lists of articles were searched. SELECTION CRITERIA: Randomised controlled trials of treatment for oesophageal reflux in adults and children with a diagnosis of both asthma and gastro-oesophageal reflux. DATA COLLECTION AND ANALYSIS: Trial quality and data extraction were carried out by two independent reviewers. Authors were contacted for confirmation or more data. MAIN RESULTS: Nine trials met the inclusion criteria. Interventions included proton pump inhibitors (n=3), histamine antagonists (n=5), surgery (n=1) and conservative management (n=1). Treatment duration ranged from 1 week to 6 months. A temporal association between asthma and gastro-oesophageal reflux was investigated in 4 trials and found to be present in a proportion of participants in these trials. Anti-reflux treatment did not consistently improve lung function, asthma symptoms, nocturnal asthma or the use of asthma medications. REVIEWER'S CONCLUSIONS: In asthmatic subjects with gastro-oesophageal reflux, (but who were not recruited specifically on the basis of reflux-associated respiratory symptoms), there was no overall improvement in asthma following treatment for gastro-oesophageal reflux. Subgroups of patients may gain benefit, but it appears difficult to predict responders.

Adult↗
PubMed1998

Prevention of preterm birth in multiple pregnancy.

Preterm birth is the greatest threat to the infants in a multiple pregnancy. This chapter focuses on strategies that aim to prevent preterm birth and concentrates on the evidence derived from randomized clinical trials and systematic review of randomized clinical trials. The options to avoid a multiple pregnancy are briefly considered. Interventions that aim to prolong pregnancy, including prophylactic cervical cerclage, prophylactic tocolysis, home uterine activity monitoring and hospitalization for bed rest, are critically appraised, as are interventions that aim to improve the outcome of preterm birth. Interventions that require additional evaluation are highlighted.

Female↗