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PubMed2000

Home care by outreach nursing for chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow obstruction, worsening exercise performance and deterioration in health. It is associated with significant morbidity, mortality and costs to health care systems. Care strategies, such as outreach nursing in the community, may reduce this burden. OBJECTIVES: To evaluate the effectiveness of outreach respiratory health care worker programmes for patients with COPD in terms of improving lung function, exercise tolerance and health related quality of life (HRQL) of patient and carer, and reducing mortality and hospital service utilisation. SEARCH STRATEGY: A search was carried out using the Cochrane Airways Group database. Bibliographies of identified RCTs were searched for additional relevant RCTs. Authors of identified RCTS were contacted for other published and unpublished studies. SELECTION CRITERIA: Only randomised control trials of patients with COPD were included. The intervention was an outreach nurse visiting patients in their homes, providing support, education, monitoring patient status and providing liaison with physicians. Interventions that used nurse practitioners who provided therapeutic intervention were also included. Studies in which the therapeutic intervention under test was physical training were not included. DATA COLLECTION AND ANALYSIS: Data extraction and study quality assessment were performed independently by two reviewers. Where further or missing data was required, authors of studies were contacted. MAIN RESULTS: Four studies were found. Three assessed mortality following twelve months of care (n=96, 152 and 301), and one after seven months(n=75). Meta-analysis demonstrated that mortality was not significantly reduced by the intervention, Peto Odds Ratio 0.72; 95 % confidence interval 0.43, 1.21. Post hoc subgroup analysis suggested that mortality was reduced by the outreach nursing programme in patients with less severe disease. Significant improvements in health related quality of life were reported in one study in moderate COPD, but not in a study in patients with severe disease. No changes in lung function or exercise performance were found in the studies where data were available. Hospital admissions were reported in only one study in patients with severe disease and no benefit was observed. REVIEWER'S CONCLUSIONS: Patients with moderate COPD may have mortality and health related quality of life gains from a nursing outreach programme, but there are no data about reductions in hospital utilisation. Patients with severe COPD do not appear to have benefit from such programmes and one large study found no reduction in hospital admissions in such patients.

Community-Institutional Relations↗
PubMed2006

Issues in the assessment of the pathologic effect of primary systemic therapy for breast cancer.

BACKGROUND: Emerging evidence suggests that induction of pathologic complete response (pCR) after primary systemic therapy (PST) is, at least to some extent, predictive of survival. However, standards for processing surgical specimens and for histopathologic evaluation of the pathologic response to therapy appear to be lacking. METHODS: To perform a systematic review of representative articles on this topic, a computerized (MEDLINE) search was undertaken followed by a manual search based on the reference lists of the publications identified. RESULTS: Several classification systems have been used to assess pathologic response to PST, the term pCR has not been applied in a consistent standardized manner, and only limited information is available about the reliability and validity of these classification systems. However, definitions of pCR can be summarized as follows: near pCR, only focal invasive tumor residues in the removed breast; quasi pCR, total or near total disappearance of invasive tumor in the removed breast; pCRinv, only in situ tumor residual in the removed breast; comprehensive pCR, no evidence of residual invasive tumor in the removed breast; strict pCR, disappearance of all tumor cells in the removed breast; comprehensive pCR (br+n), no evidence of residual invasive tumor in the breast and axillary nodes; strict pCR (br+n), no malignant tumor cells in the removed breast and axillary nodes. Comparison of the use of the term "pCR" in various trials reveals that it is not applied equivalently in these studies. CONCLUSION: Assessment of pCR needs to be standardized, with verification for reliability and validity. For now, the non-equivalency in the definition of pCR should be taken into account when comparing the results of PST.

Antineoplastic Agents↗
PubMed2002

Surgical versus non-surgical treatment for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is the clinical condition resulting from the entrapment of the median nerve in the wrist. It has been accepted as the most frequent entrapment neuropathy. The most common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. There may be weakness and atrophy of the thenar muscles associated with sensory loss in the affected fingers. There is no universally accepted therapy for carpal tunnel syndrome. Surgical treatment is widely preferred to non-surgical or conservative therapies for overtly symptomatic patients, while mild cases are usually not treated. OBJECTIVES: The objective of this review is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment in improving clinical outcome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register for randomised or quasi-randomised trials as well as MEDLINE, EMBASE and LILACS (to July 2001). We checked the bibliographies in relevant papers and contacted the authors to obtain information about other published or unpublished studies. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility of the trials. MAIN RESULTS: Only one randomised controlled trial was found. It included 22 female patients, 11 allocated to surgical section of the anterior carpal ligament and 11 to splinting for one month. The trial was not blinded and it is not clear if the allocation was properly concealed. Data reported allowed an intention-to-treat analysis on two secondary outcomes. The results favour surgery for both of them. There was a significant clinical improvement at one year follow-up in 10 out of 11 patients allocated to surgery and two out of 11 allocated to splinting (relative risk 5.00, 95% confidence interval 1.41, 17.76). Eight out of 11 patients allocated to splinting required surgery during follow-up, compared with apparently no re operation in the surgical group (relative risk 0.06, 95% confidence interval 0.00, 0.91). REVIEWER'S CONCLUSIONS: Surgical treatment of carpal tunnel syndrome seems to be better than splinting. There is a need for randomised controlled trials comparing surgical and non-surgical therapies for carpal tunnel syndrome, particularly in patients with mild symptoms in whom there is greater uncertainty concerning the balance of risks versus benefit of surgical therapy.

Carpal Tunnel Syndrome↗
PubMed2006

Nutritional support after open liver resection: a systematic review.

BACKGROUND: Perioperative nutrition in patients with limited liver function after partial hepatic resection is still controversial. In particular, the significance of perioperative total enteral nutrition remains unresolved. The aim of this review is to investigate the impact of early postoperative total enteral nutrition on convalescence after partial liver resection. MATERIALS AND METHODS: In an internet-based Medline-Search (time course: 1960-08/2005) a total of five prospective, randomized controlled trials were found comparing the impact of enteral and parenteral nutrition after liver resection. After study validity had been established, a systematic review was undertaken (odds ratio, 95% confidence interval, p < 0.05 level of significance; Review Manager 4.2, The Cochrane Collaboration). Primary endpoints were complication rate (infection, organ malfunction) and mortality. Standardized immune parameters were also surveyed. RESULTS: Statistical analysis showed that enteral nutrition resulted in a significantly lower rate (p = 0.04) of wound infection and catheter-related complications than parenteral nutrition did. No statistically significant differences in mortality due to enteral or parenteral nutrition could be found. Patients receiving enteral nutrition showed better postoperative immune competence. CONCLUSION: Early enteral nutrition after liver resection is a safe procedure. Compared to parenteral nutrition it is associated with a decreased incidence of postoperative complications. Facing the inhomogeneity of these trials, especially in nutrition protocols and end points, this first systematic review stresses the need for an update of the importance of early enteral nutrition after liver resection within randomized controlled multicenter trials.

Hepatectomy↗
PubMed2001

Directly observed therapy for treating tuberculosis.

BACKGROUND: Up to half the people with tuberculosis do not complete their treatment. Strategies to improve adherence to diagnostic and treatment regimens are therefore important. OBJECTIVES: To assess the effects of directly observed therapy by an appointed agent (health worker, community volunteer, or family member) on cure and treatment completion in people on treatment for tuberculosis. SEARCH STRATEGY: We searched The Cochrane Controlled Trials Register, the Cochrane Infectious Diseases Group specialized trials register, MEDLINE, EMBASE, LILACS, and reference lists of articles. We also contacted experts in the field. SELECTION CRITERIA: Randomized and quasi-randomized trials of direct observation of tablet swallowing compared with self treatment for tuberculosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Four studies (n = 1603 participants) included. There was no difference detected between direct observation and self treatment for cure (Relative Risk [RR] 1.06, 95% confidence interval [CI] 0.98 to 1.14); and for cure plus treatment completion (RR 1.06, 95% CI 1.00 to 1.13). A stratified analysis by the appointed agent (health professional, lay health worker, or family/community member) did not reveal any important differences. One study conducted in an optimal setting in which patients were given a choice of supervisor did show modest benefit: cure (RR 1.13, 95% CI 1.04 to 1.24); cure plus treatment completion (RR 1.11, 95% CI 1.03 to 1.18). REVIEWER'S CONCLUSIONS: Randomized trials provide no evidence that directly observed therapy in low and middle income country settings improves cure or treatment completion rates in patients with tuberculosis.

Antitubercular Agents↗
PubMed2000

Moderately early (7-14 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants.

BACKGROUND: Corticosteroids have been used late in the neonatal period to treat chronic lung disease (CLD) in preterm babies and early to try to prevent it. CLD is likely to be the result of persisting inflammation in the lung and the use of powerful anti-inflammatory drugs like dexamethasone has some rationale. Early use tends to be associated with increased adverse effects so that studies of moderately early treatment (7-14 days postnatal) might have the dual benefits of fewer side effects and onset of action before chronic inflammation is established. OBJECTIVES: To determine if moderately early (7-14 days) postnatal corticosteroid treatment vs control (placebo or nothing) is of benefit in the prevention and/or treatment of early chronic lung disease in the preterm infant. SEARCH STRATEGY: Randomised controlled trials of postnatal corticosteroid therapy were sought from the Oxford Database of Perinatal Trials, Cochrane Database of Controlled Trials, Medline, hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists. SELECTION CRITERIA: Randomised controlled trials of postnatal corticosteroid treatment from 7-14 days of birth in high risk preterm infants were selected for this review. DATA COLLECTION AND ANALYSIS: Data regarding clinical outcomes including mortality up to 28 days and before discharge, failure to extubate, mortality and / or chronic lung disease at 28 days and 36 weeks, CLD at 28 days and 36 weeks, infection, hyperglycaemia, hypertension, severe retinopathy of prematurity (ROP), pneumothorax, necrotizing enterocolitis (NEC), gastrointestinal bleeding, severe intraventricular hemorrhage (IVH), hypertrophic cardiomyopathy, late rescue with dexamethasone and abnormal neurological examination at follow-up were abstracted and analysed using Revman 4.0.4. MAIN RESULTS: Moderately early steroid treatment (vs placebo or nothing) reduced mortality by 28 days, chronic lung disease at 28 days and 36 weeks, and death or chronic lung disease at 28 days or 36 weeks. Earlier extubation was facilitated. There was no significant effect on the rates of pneumothorax, severe ROP, and NEC. Adverse effects included hypertension, hyperglycaemia, gastrointestinal bleeding, hypertrophic cardiomyopathy and infection. Steroid-treated infants were less likely to need late rescue with dexamethasone. There was only one small study of longterm follow-up and it did not show any increase in adverse neurological outcome. REVIEWER'S CONCLUSIONS: Moderately early corticosteroid therapy (started at 7-14 days) reduces neonatal mortality and CLD, but at the cost of important short term adverse effects. No reliable evidence concerning long term effects is provided by the trials included in this review. In view of the evidence of an important increase in cerebral palsy and other adverse neurodevelopmental outcomes from trials in which postnatal steroid was begun either earlier or later than 7-14 days, there are reasonable grounds for extending this concern to moderately early initiation of steroid therapy. More research is urgently needed, including long term follow-up of survivors included in previous and any future trials, before the benefits and risks of postnatal steroid treatment, including initiation at 7-14 days, can be reliably assessed.

Anti-Inflammatory Agents↗
PubMed2006

The promise and pitfalls of systematic reviews.

The systematic review "movement" that has transformed medical journal reports of clinical trials and reviews of clinical trials has taken hold in public health, with the most recent milestone, the publication of the first edition of The Guide to Community Health Services in 2005. In this paper we define and distinguish current terms, point out important resources for systematic reviews, describe the impact of systematic review on the quality of primary studies and summaries of the evidence, and provide perspectives on the promise of systematic reviews for shaping the agenda for public health research. Several pitfalls are discussed, including a false sense of rigor implied by the terms "systematic review" and "meta-analysis" and substantial variation in the validity of claims that a particular intervention is "evidence based," and the difficulty of translating conclusions from systematic reviews into public health advocacy and practice.

Evidence-Based Medicine↗
PubMed2000

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease.

BACKGROUND: Heartburn affects 25% of the adult population on a monthly basis and represents the core symptom of gastro-oesophageal reflux disease (GORD). Treatment is readily available and puts a large demand on healthcare budgets. Research in the past has focused largely on the treatment of oesophagitis. A majority of GORD patients show no endoscopic abnormalities and in daily practice most patients are treated empirically. OBJECTIVES: Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in the empirical treatment of GORD and the treatment of endoscopy negative reflux disease (ENRD). SEARCH STRATEGY: Electronic searches were performed of the Cochrane Controlled Trials Register, MEDLINE and EMBASE. Bibliographies were screened. SELECTION CRITERIA: Included were randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be classifiable in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis). DATA COLLECTION AND ANALYSIS: Data from included trials were extracted by two reviewers independently. The impact of interventions was expressed as relative risks (RR) together with 95% confidence intervals (95% CI). Meta-analysis was only performed if there were sufficient trials of similar comparisons reporting the same outcomes. Relative risks were combined for binary outcomes. MAIN RESULTS: Twenty-one trials were included: eleven in the empirical treatment group, seven in the ENRD group and three in both. In empirical treatment of GORD the RR for heartburn remission in placebo-controlled trials for PPI was 0.35 (1 trial, 95% CI 0.26 to 0.46), for H2RAs 0.77 (2 trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (1 trial, 95% CI 0.73 to 1.01). In direct comparison PPIs were significantly (p<0.05) more effective than H2RAs (3 trials, RR 0.67, 95% CI 0.57 to 0.80) and prokinetic's (2 trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, RR for heartburn remission for PPI versus placebo was 0.68 (4 trials, 95% CI 0.53 to 0.88) and for H2RA versus placebo was 0.84 (2 trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.69 (2 trials, 95% CI 0.39 to 1.20) and versus prokinetic 0.72 (1 trial, 95% CI 0.56 to 0.92). REVIEWER'S CONCLUSIONS: The findings in this review suggest that antisecretory drugs are effective in the empirical treatment of complaints likely to originate from GORD and in treatment of ENRD and furthermore that PPIs are superior to H2RAs in empirical treatment of typical GORD symptoms.

Endoscopy, Digestive System↗
PubMed2000

Balneotherapy for rheumatoid arthritis and osteoarthritis.

BACKGROUND: Balneotherapy (hydrotherapy or spa therapy) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain and as a consequence to relieve patients' suffering and make them feel well. OBJECTIVES: To perform a systematic review to assess the effects of balneotherapy for rheumatoid arthritis and osteoarthritis. SEARCH STRATEGY: Using the Cochrane search strategy, studies were found by screening: 1) The Medline CD-ROM database from 1966 to June 1999 and 2) the database from the Cochrane Field 'Rehabilitation and Related Therapies', which contains also studies published in journals not covered by Medline. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. To perform an adequate assessment of the methodological quality the languages of the publications had to be: Dutch, English, French or German. Date of the most recent literature search: June, 1999 SELECTION CRITERIA: Studies were eligible if they were randomized controlled trials (RCT) comparing balneotherapy with any intervention or with no intervention. Patients included had rheumatoid arthritis (RA), osteoarthritis (OA) or some other form of arthritis. Trials incorporating patients with definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) (Ropes 1958) (these criteria have changed over time) or by the criteria of Steinbrocker (1949) were regarded as a separate group. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be the main outcome measures. DATA COLLECTION AND ANALYSIS: A criteria list used to assess the methodological quality was the one developed at the Department of Epidemiology at the Maastricht University, called "the Maastricht list". The quality scores and data abstraction of the studies were carried out independently by two reviewers (HdV, RdB). Disagreements were solved by consensus. MAIN RESULTS: Ten trials with 607 patients were included in this review. Most trials reported positive findings, but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. Just one of the randomized trials mentioned an intention-to-treat analysis and only three performed a comparison of effects between groups. Pooling of the data was not performed, because of heterogeneity of the studies, multiple outcome measurements, and, apart from two studies, the overall data presentation was too scarce to enable pooling of the data. REVIEWER'S CONCLUSIONS: One cannot ignore the positive findings reported in most trials. However the scientific evidence is weak because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, quality of life), Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the efficacy of balneotherapy cannot be provided at this time. Flaws found in the reviewed studies could be avoided in future trials.

Arthritis, Rheumatoid↗
PubMed2000

Nedocromil sodium for preventing exercise-induced bronchoconstriction.

BACKGROUND: Exercise-induced asthma causes cough, dyspnea, wheeze and chest tightness. Management of focuses on prevention through pharmaco-therapy and alternate strategies. Single use, pre-exercise beta2-agonists and non-steroidal anti-inflammatory agents such as the cromones are the most common treatments. OBJECTIVES: The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise-induced bronchoconstriction. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. SELECTION CRITERIA: Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise-induced bronchoconstriction in people over six years of age. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. MAIN RESULTS: Twenty randomised controlled trials involving 280 participants were identified. 15-60 min following inhalation of 4 mg nedocromil, the maximum fall in forced expiratory volume in one second due to exercise was improved by 15.6%, (95% CI:13.2 to 18.1) compared to the placebo response. The maximum percentage fall in peak expiratory flow rate was of the same magnitude (weighted mean difference 15.0%; 95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. The relative magnitude of its effect was greatest in patients with more severe exercise-induced bronchoconstriction (defined as an exercise-induced fall in lung function > 30% from baseline). There were no significant adverse effects reported. REVIEWER'S CONCLUSIONS: Nedocromil sodium used before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise-induced bronchoconstriction.

Adolescent↗
PubMed2001

Local treatments for cutaneous warts.

BACKGROUND: Viral warts caused by the human papilloma virus represent one of the most common diseases of the skin. Any area of skin can be affected although the hands and feet are by far the commonest sites. A very wide range of local treatments are available. OBJECTIVES: To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (March 1999), the Skin Group trials register (March 1999), MEDLINE (1966 to August 2000), EMBASE (1980 to August 2000) and a number of other key biomedical and health economics databases. In addition the cited references of all trials identified and key review articles were searched. Pharmaceutical companies involved in local treatments for warts and experts in the field were contacted. SELECTION CRITERIA: Randomized controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent human hosts were included. DATA COLLECTION AND ANALYSIS: Study selection and assessment of methodological quality were carried out by two independent reviewers. MAIN RESULTS: Forty-nine trials were identified which fulfilled the criteria for inclusion in the review. The evidence provided by these studies was generally weak because of poor methodology and reporting. In 17 trials with placebo groups that used participants as the unit of analysis the average cure rate of placebo preparations was 30% (range 0 to 73%) after an average period of 10 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model. Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two other trials comparing cryotherapy with salicylic acid no significant difference in efficacy was demonstrated. There was no consistent evidence for the effectiveness of intralesional bleomycin. Four studies, using warts rather than individuals as the unit of analysis, had widely varying results which could not be meaningfully pooled. There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 17/40 (43%) respectively, odds ratio 5.42 (95% confidence interval 1.99 to 14.75), random effects model. Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy. Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments. REVIEWER'S CONCLUSIONS: There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and no convincing evidence that it is any more effective than simple topical treatments. Dinitrochlorobenzene appears to be effective but no more so than the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

Administration, Topical↗
PubMed2002

Bromocriptine/levodopa combined versus levodopa alone for early Parkinson's disease.

BACKGROUND: Drugs that mimic dopamine such as bromocriptine were introduced as monotherapy or in a combination with LD in the hope that this approach would prevent or delay the onset of motor complications in patients with Parkinson's disease (PD). However, hitherto, the role of bromocriptine (BR) in this issue has remained controversial. The present study is a systematic review of all randomised controlled trials of bromocriptine/levodopa (BR/LD) combination therapy compared with levodopa (LD) monotherapy in PD. OBJECTIVES: To assess the efficacy and safety of BR/LD combination therapy in delaying the onset of motor complications associated with LD monotherapy in patients with PD. SEARCH STRATEGY: Sources including the Cochrane Library, the search strategy of the Movement Disorders Group (includes computerised searches of MEDLINE and EMBASE and hand searching of appropriate neurology journals), reference lists of the reviews found by the MEDLINE and EMBASE search-strategy, Sandoz -now Novartis- (manufacturer of BR), PPD Pharmaco, symposia reports, PD handbooks, contacts with colleagues who had co-ordinated trials on BR and reference lists of all included studies were used to identify randomised controlled trials (RCTs) of interest. SELECTION CRITERIA: Randomised trials were eligible for inclusion if they evaluated the efficacy of BR/LD combination therapy for delaying the onset of motor complications compared to LD monotherapy in PD patients. Outcome measures that were evaluated included occurrence and severity of motor complications, scores on impairment and disability, and the occurrence of side effects and dropouts. DATA COLLECTION AND ANALYSIS: To determine the feasibility of a quantitative systematic review two independent reviewers evaluated the methodological quality of identified trials. MAIN RESULTS: The methodological quality of five trials showed important shortcomings. All studies failed to adequately describe randomisation procedures. Only two were carried out according to a double-blind design. Differences between studies concerning the mean age of the patients, the BR titration phase, the maximum achieved daily dose of LD (62.5-1000 mg) and BR (5-50 mg), and the applied outcomes were found. Our results show no evidence of consistent differences concerning the occurrence and severity of motor complications, scores of impairment and disability and the occurrence of side effects between both treatment groups. REVIEWER'S CONCLUSIONS: This systematic review found no evidence in support of early bromocriptine/levodopa combination therapy as a strategy to prevent or delay the onset of motor complications in the treatment of PD.

Antiparkinson Agents↗
PubMed2002

[Meta-analysis and evidence based medicine].

Meta-analysis is a statistical method for combining the results of available research studies to increase statistical power. The steps of meta-analysis are identification of question, search and selection of trials and analysis. Evidence based medicine (EBM) is integrating individual clinical expertise with the best available external clinical evidence from systematic research. The practice of EBM consists of formulated clinical question, systematic review, critical appraisal, application for patients and performance review. We must notice the results of meta-analysis and evidence are keeping up to date. We should use them with critical appraisal skill and should not criticize without good understanding.

Evidence-Based Medicine↗
PubMed2000

Amantadine and rimantadine for preventing and treating influenza A in adults.

OBJECTIVES: Amantadine hydrochloride and rimantadine hydrochloride have antiviral properties, but they are not widely used due to a lack of knowledge of their properties and concerns about possible adverse effects. The objective of this review was to assess the effects and safety of amantadine and rimantadine in healthy adults. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Medline, Embase and reference lists of articles. We also contacted manufacturers, researchers and authors. SELECTION CRITERIA: Randomised and quasi-randomised studies comparing amantadine and/or rimantadine with placebo, control antivirals or no intervention, or comparing doses or schedules of amantadine and/or rimantadine in healthy adults. DATA COLLECTION AND ANALYSIS: For prevention trials the numbers of participants with clinically defined influenza, with serologically confirmed clinical influenza A and adverse effects were analysed. Analysis for treatment trials was of the mean duration of fever and adverse effects. MAIN RESULTS: Amantadine prevented 23% of clinical influenza cases (95% confidence interval 11% to 34%), and 63% of serologically confirmed clinical influenza A cases (95% confidence interval 42% to 76%) Amantadine reduced duration of fever by one day (95% confidence interval 0.7 to 1.3). Rimantadine demonstrated comparable effectiveness, but there were fewer trials and the results for prevention were not statistically significant. Both amantadine and rimantadine induced significant gastrointestinal adverse effects. Adverse effects of the central nervous system adverse and study withdrawals were significantly more common with amantadine than rimantadine. REVIEWER'S CONCLUSIONS: Amantadine and rimantadine have comparable effectiveness in the prevention and treatment of influenza A in healthy adults, although rimantadine induces fewer adverse effects than amantadine.

Adult↗
PubMed2000

Interventions for treating headlice.

BACKGROUND: Infection with head lice is a widespread condition in developed and developing countries. Infection occurs most commonly in children, but also affects adults. If left untreated the condition can become intensely irritating and skin infections may occur if the bites are scratched. OBJECTIVES: The aim of this review was to assess the effects of interventions for head lice. SEARCH STRATEGY: Trials register of The Cochrane Infectious Diseases Group; Medline; Embase; Science Citation Index; Biosis and Toxline; reference lists of relevant articles; pharmaceutical companies producing pediculicides (published and unpublished trials); UK and US Regulatory Authorities. SELECTION CRITERIA: Randomised trials (published and unpublished) or trials using alternate allocation were sought which compared pediculicides with the same and different formulations of other pediculicides, and pediculicides with physical methods. DATA COLLECTION AND ANALYSIS: Of the 70 identified studies, only three met the inclusion criteria and one is awaiting assessment. Two reviewers independently assessed trial quality. One reviewer extracted the data. MAIN RESULTS: We found no evidence that any one pediculicide has greater effect than another. The two studies comparing malathion and permethrin with their respective vehicles showed a higher cure rate for the active ingredient than the vehicle. The third study comparing synergised pyrethrins with permethrin showed their effects to be equivalent. Adverse effects were reported in a number of trials and were all minor, although reporting quality varied between trials. REVIEWER'S CONCLUSIONS: Permethrin, synergised pyrethrin and malathion were effective in the treatment of head lice. However, the emergence of drug resistance since these trials were conducted means there is no direct contemporary evidence of the comparative effectiveness of these products. The 'best' choice will now depend on local resistance patterns. There is currently no evidence from trials to indicate the effectiveness of physical methods, such as combing/'BugBusting' or other chemical control methods such as the use of herbal treatments, when used in the curative treatment of head lice. Future trials should take into account the methodological recommendations that arise from this review.

Adult↗
PubMed2000

Electroconvulsive therapy for schizophrenia.

BACKGROUND: Electroconvulsive therapy (ECT) involves the induction of a seizure (fit) for therapeutic purposes by the administration of a low frequency electrical stimulus shock via electrodes applied to the scalp. At present it is used for those with schizophrenia but its effects are unclear. OBJECTIVES: To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning in those with schizophrenia. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), Medline (1966-1996), PsycLIT (1974-1996) and SCISEARCH (1996) were undertaken. The references of all identified studies were investigated. SELECTION CRITERIA: All randomised controlled trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics for people with schizophrenia, schizoaffective disorder or chronic mental disorder. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently and analysed the data on an intention to treat basis. MAIN RESULTS: Less people with schizophrenia treated with ECT showed no improvement in general functioning when compared to those given placebo in the short term (OR 0.48 CI 99% 0.26-0.90). This effect, however, does not last. However, ECT is less effective than antipsychotic drug treatment for those with schizophrenia. Limited evidence exists to suggest that combining antipsychotic drugs and ECT increases the rate and extent of clinical improvement, in the short term, in one out of every five to six people. The evidence for the efficacy of ECT in the medium to long term is equivocal. Electroconvulsive therapy is also more effective than the now obsolete insulin coma treatment. REVIEWER'S CONCLUSIONS: There is some evidence to support the use of ECT for those with schizophrenia for short term relief of symptoms. Electroconvulsive therapy may be advocated as an adjunct to antipsychotic medication for those with schizophrenia who show a limited response to medication alone but the evidence for this is not strong. In fact in spite of more than five decades of widespread clinical use, the administration of ECT to those with schizophrenia lacks a strong research base.

Electroconvulsive Therapy↗