SEARCHING THE MEDICAL LITERATURE. INFORMATION RETRIEVAL (MEDLARS) AT THE NATIONAL LIBRARY OF MEDICINE.
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Abstracting and Indexing↗
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MEDLARS AND THE LIBRARY COMMUNITY.
The intention of the National Library of Medicine is to share with other libraries the products and the capabilities developed by the MEDLARS system. MEDLARS will provide bibliographic services of use to other libraries from the central system. The decentralization of the central system to permit libraries with access to computers to establish local machine retrieval systems is also indicated. The implications of such decentralization for the American medical library network and its effect on library evolution are suggested, as are the implications for international development of mechanized storage and retrieval systems.
Abstracting and Indexing↗
Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.
BACKGROUND: Heavy menstrual bleeding (HMB) or menorrhagia is an important cause of ill health in women. Surgical treatment of HMB often follows failed or ineffective medical therapy and the definitive treatment is hysterectomy but this is a major surgical procedure with significant physical and emotional complications and social and economic costs. A number of less invasive surgical techniques (e.g. endometrial resection and laser ablation) have been developed with the purpose of removing the entire thickness of the endometrium. The benefits claimed for these therapies are reduced trauma and post-operative complications to the woman, reduced need for a general anaesthetic, direct cost savings to the health service due largely to a shift from inpatient to day case treatment and indirect cost savings to society as women return more quickly to their usual activities. However, endometrial hysteroscopic techniques are not always completely successful and additional surgical treatment is required in a proportion of cases. Although initially the resource and patient costs of these techniques are much cheaper than the cost of hysterectomy, the need for re treatment at a later stage may reduce the cost differential. Thus, the effectiveness of these techniques to improve a woman's perception of her own wellbeing long term has yet to be confirmed. OBJECTIVES: The objective of this review is to compare endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding (HMB). SEARCH STRATEGY: Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Sub fertility 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 hand searching. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women. DATA COLLECTION AND ANALYSIS: Five RCTs were identified that fulfilled the inclusion criteria for this review. For two trials, a number of publications were identified which assessed different outcomes and different follow up time points for the same patients. The reviewers extracted the data independently and odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data. Outcomes analysed included improvement in menstrual blood loss, satisfaction, change in quality of life, duration of surgery and hospital stay, time to return to work, adverse events and requirement for repeat surgery because of failure of the initial surgical treatment. MAIN RESULTS: There was a significant advantage in favour of hysterectomy in the improvement in HMB and satisfaction rates (up to 4 years post surgery) compared with endometrial destruction techniques. Although many quality of life scales reported no differences between surgery groups, there was some evidence of a greater improvement in general health for hysterectomy patients. Duration of surgery, hospital stay and recovery time were all shorter following endometrial destruction. Most adverse events, both major and minor, were significantly more likely after hysterectomy and before discharge from hospital. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection. Repeat surgery because of failure of the initial treatment, either endometrial ablation or hysterectomy, was more likely after endometrial destruction than hysterectomy. (ABSTRACT TRUNCATED)
Endometrium↗
Percutaneous endoscopic gastrostomy in patients undergoing resection for oral tumors: a retrospective review of complications and outcomes.
PURPOSE: The use of a percutaneous endoscopic gastrostomy (PEG) in patients undergoing resection for oral tumors is not universal, and varying complication rates have been reported. This study reviews our experience with the use of a PEG as an adjunct in this setting. MATERIALS AND METHODS: The records of patients treated for oral tumors by oral and maxillofacial surgery were reviewed retrospectively. All patients undergoing resection for oral tumors and having a PEG were included. Patient age, gender, disease type, and stage, as well as type of operation, were recorded. Data obtained included the timing of PEG placement, duration of PEG use, and PEG complications. Patient weight and body mass index (BMI) were abstracted when recorded preoperatively and about 2 weeks and between 4 and 8 weeks postoperatively. Weight and BMI results were subjected to statistical analysis. RESULTS: Fifty PEGs were placed in 49 patients with oral tumors. The mean age of the patients was 61 years. More than 90% of tumors were squamous cell carcinomas. Most PEG tubes were placed at the time of resection by 1 surgeon and were retained for a mean duration of 114 days. A minor complication rate of 10% and a major complication rate of 8% were noted. Weight decreased significantly by 2.9% from preoperative level to week 2, but there was no other significant difference found between any other weight or BMI measurement. Incidental findings on PEG placement included Barrett's metaplasia in one patient and gastric adenocarcinoma in another. CONCLUSIONS: The use of PEG in patients with oral tumors at our institution was found to be effective in maintaining adequate nutrition, as assessed by weight and BMI, during recovery and convalescence. There is an acceptable low complication rate. Use of an experienced endoscopist and PEG placement at the time of resection are advocated.
Adult↗
BIBLIOGRAPHIC ASPECTS OF MEDLARS.
When MEDLARS becomes operational in 1964, it should provide the resources for a comprehensive, integrated bibliographical publication and retrieval system. The publications Index Medicus and Cumulated Index Medicus will be modified in format, arrangement, and method of preparation; other published bibliographies will also be affected by the new system. This paper describes the characteristics of both the publication and retrieval phases of MEDLARS.
Abstracting and Indexing↗
Cyclical progestogens for heavy menstrual bleeding.
BACKGROUND: Excessively heavy menstrual bleeding (HMB) or menorrhagia is an important cause of ill health in women. Eighty per cent of women treated for HMB have no anatomical pathology and so medical therapy, with the avoidance of possibly unnecessary surgery, is an attractive alternative. Of the wide variety of medications used to reduce heavy menstrual bleeding, oral progestogens are the most commonly prescribed in many western countries, although there is little objective evidence to support their use, especially in women with ovulatory menstruation. This review assesses the effectiveness of 2 different regimens of oral progestogens in reducing ovulatory HMB. OBJECTIVES: The primary objective of this review is to investigate the effectiveness of oral progestogen therapy taken either during the luteal phase or for a longer course of 21 days 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. In most cases, the first author of each included trial was contacted. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of oral progestogen therapy versus 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 causes for their heavy menstrual blood loss. DATA COLLECTION AND ANALYSIS: Seven randomised controlled trials (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. MAIN RESULTS: No RCTs comparing progestogen treatment with placebo were identified. Comparisons between oral progestogens and other medical therapies were assessed separately according to dosage regimen, progestogens given during the luteal phase of the menstrual cycle and progestogens given for 21 days between day 5 and 26. Progestogen therapy during the luteal phase was significantly less effective at reducing menstrual blood loss when compared with tranexamic acid, danazol and the progesterone releasing intrauterine system (IUS) and there was also a strong non-significant trend in favour of nonsteroidal anti-inflammatory drugs (NSAIDs). Duration of menstruation was significantly longer with the progesterone IUS when compared with oral progestogen therapy but significantly shorter under danazol treatment. Compliance and acceptability of treatment where measured did not differ between treatments. Adverse events were significantly more likely under danazol when compared with progestogen treatment. Change in quality of life was not significantly different with progestogen and tranexamic acid therapy but there was a non-significant trend in favour of tranexamic acid for all three categories. Progestogen therapy administered from day 5 to 26 of the menstrual cycle was significantly less effective at reducing menstrual blood loss than the progestogen releasing intrauterine system (LNG IUS) although the reduction from baseline was significant for both groups. The odds of the menstrual period becoming "normal" (ie <80mls/cycle) were also less likely in patients treated with norethisterone (NET) (days 5 to 26) compared to patients treated with LNG IUS. A significantly higher proportion of NET patients found their treatment unacceptable compared to LNG IUS patients. However, the adverse events breast tenderness and intermenstrual bleeding were more likely in the patients with the IUS. (ABSTRACT TRUNCATED)
Administration, Oral↗
Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding.
BACKGROUND: The decline in circulating oestrogen around the time of the menopause often induces unacceptable symptoms that affect the health and well being of women. Hormone replacement therapy (both unopposed oestrogen and oestrogen and progestogen combinations) is an effective treatment for these symptoms. In women with an intact uterus, unopposed oestrogen may induce endometrial stimulation and increase the risk of endometrial hyperplasia and carcinoma. The addition of progestogen reduces this risk but may cause unacceptable symptoms, bleeding and spotting which can affect adherence to therapy. OBJECTIVES: The objective of this review is to assess which hormone replacement therapy regimens provide effective protection against the development of endometrial hyperplasia and/or carcinoma with a low rate of abnormal vaginal bleeding. 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 contacted for unpublished data. In most cases, the corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of unopposed oestrogen therapy, combined continuous oestrogen-progestogen therapy and sequential oestrogen-progestogen therapy with each other and placebo administered over a minimum treatment period of six months. Trials had to assess which regimen was the most protective against the development of endometrial hyperplasia/carcinoma and/or caused the lowest rate of irregular bleeding. DATA COLLECTION AND ANALYSIS: Twenty three RCTs were identified and five were excluded. The reviewers assessed the eighteen included studies for quality, extracted the data independently and odds ratios for dichotomous outcomes were estimated. Outcomes analysed included frequency of endometrial hyperplasia or carcinoma, frequency of irregular bleeding and unscheduled biopsies or dilation and curettage, and adherence to therapy. MAIN RESULTS: Unopposed moderate or high dose oestrogen therapy was associated with a significant increase in rates of endometrial hyperplasia with increasing rates at longer duration of treatment and follow up. Odds ratios ranged from 5.4 (1. 4-20.9) for 6 months of treatment to 16.0 (9.3-27.5) for 36 months of treatment with moderate dose oestrogen (in the PEPI trial, 62% of those who took moderate dose oestrogen had some form of hyperplasia at 36 months compared to 2% of those who took placebo). Irregular bleeding and non adherence to treatment were also significantly more likely under these unopposed oestrogen regimens with greater effects with higher dose therapy. There was no evidence of increased hyperplasia rates, however, with low dose oestrogen. The addition of progestogens, either in continuous combined or sequential regimens, helped to prevent the development of endometrial hyperplasia and improved adherence to therapy (odds ratios of 3.7 for sequential therapy and 6.0 for continuous therapy). Irregular bleeding, however, was more likely under a continuous than a sequential oestrogen-progestogen regimen (OR = 2.3, 95% CI 2.1-2.5) but at longer duration of treatment, continuous therapy was more protective than sequential therapy in preventing endometrial hyperplasia (OR = 0.3, 95% CI 0.1-0.97). There was evidence of a higher incidence of hyperplasia under long cycle sequential therapy (progestogen given every 3 months) compared to monthly sequential therapy (progestogen given every month). No increase in endometrial cancer was seen in any of the treatment groups during the limited duration (maximum of 3 years) of these trials. (ABSTRACT TRUNCATED)
Endometrial Hyperplasia↗
SCOPE AND SERVICES OF THE U.S. NATIONAL LIBRARY OF MEDICINE.
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Abstracting and Indexing↗
Routine preoperative testing: a systematic review of the evidence.
OBJECTIVES. To review the available evidence on the value of routine preoperative testing in healthy or asymptomatic adults. To assess the completeness of existing reviews of preoperative testing and how applicable their conclusions are to the UK. To identify areas for further research. HOW THE RESEARCH WAS CONDUCTED. The databases Medline, Embase, Biological Abstracts, Science Citation Index and HealthSTAR were thoroughly searched for relevant articles which were then classified and appraised. The databases of the Centre for Reviews and Dissemination (DARE and NHS Economic Evaluations Database) and the Cochrane Collaboration (the Cochrane Library) were also used to verify the completeness of the search. In this review, 'routine' tests are defined as those ordered for an asymptomatic, apparently healthy individual in the absence of any specific clinical indication, to identify conditions undetected by clinical history and examination. RESEARCH FINDINGS. No controlled trials of the value of the following routine preoperative tests have been published. All available evidence reports the results of case-series. CHEST X-RAY. Few studies allow the outcome of routine chest X-rays to be distinguished from those of indicated chest X-rays, and fewer have gone beyond abnormality yields to examine the impact on clinical management. Findings from routine preoperative chest X-ray are reported as abnormal in 2.5-37.0% of cases, and lead to a change in clinical management in 0-2.1% of patients. The effect on patient outcomes is unknown. Both abnormality yield and impact on patient management rise with age and poorer American Society of Anesthesiologists (ASA) status. The limited evidence on the value of a chest X-ray as a baseline measure suggests that it will be of value in less than 9% of patients. ELECTROCARDIOGRAPHY. The findings from routine preoperative electrocardiograms (ECGs) are abnormal in 4.6-31.7% of cases, and lead to a change of management in 0-2.2% of patients. The effect on patient outcomes is unknown. The proportion of abnormal tests rises with age and worsening ASA status. The predictive power of preoperative ECGs for postoperative cardiac complications in non-cardiopulmonary surgery is weak. There is no evidence to support the value of recording a preoperative ECG as a 'baseline.' HAEMOGLOBIN MEASUREMENT AND BLOOD COUNTS. Routine preoperative measurement shows that the haemoglobin level may be lower than 10-10.5 g/dl in up to 5% of patients, but that it is rarely lower than 9 g/dl. The routine test leads to a change of management in 0.1% to 2.7% of patients. Routine preoperative measurement shows that the platelet count is abnormally low in less than 1.1% of patients, and that platelet count results rarely if ever lead to change in management of patients. Routine preoperative white blood cell count is abnormal in less than 1% of patients, and rarely if ever leads to change in management of patients. TESTS OF HAEMOSTASIS. Abnormalities of bleeding time, prothrombin time and partial thromboplastin time are found in up to 3.8%, 4.8% and 15.6% of routine preoperative tests, respectively. The results of these tests very rarely lead to change in the clinical management of patients. BIOCHEMISTRY. In routine preoperative tests of serum biochemistry, abnormal levels of sodium or potassium are found in up to 1.4% of patients, and abnormal levels of urea or creatinine are found in up to 2.5% of patients. Abnormal levels of glucose are found in up to 5.2% of patients. These abnormalities rarely lead to change in clinical management of patients. URINE TESTING. Routine preoperative urinalysis finds abnormal results in 1-34.1% of patients, and leads to a change of management in 0.1-2.8% of patients. The only abnormality that leads to a change in management of patients is the finding of white blood cells in the urine. There is no good evidence that preoperative abnormal urinalysis is associated with any postoperative complication in non-urinary tract surgery. (ABSTRACT TRUNCATED)
Adolescent↗
MEDICAL SUBJECT HEADINGS IN MEDLARS.
Use of an identical subject heading list for both machine searching and publication creates problems. Necessary compromises include precoordination of some headings for publication and use of some coordinates in the computer system that are not appropriate for a printed index. Determination of the headings under which a citation will appear in Index Medicus and those which will be used for it only in the computer requires anticipation of the way the published index will be used for search. Methods of selecting new terms are discussed and opinions solicited. The computer will be used in several ways to update the system and provide for annual publication of the subject heading list.
Abstracting and Indexing↗
Artemisinin derivatives for treating uncomplicated malaria.
BACKGROUND: Artemisinin derivatives are a relatively new group of drugs with antimalarial properties. As resistance to other antimalarial drugs continues to increase, artemisinin drugs may be useful alternatives. OBJECTIVES: The objective of this review was to assess the effects of artemisinin drugs for treating uncomplicated falciparum malaria. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase, Science Citation Index, Lilacs, African Index Medicus; conference abstracts and reference lists of relevant articles. We contacted organisations, researchers in the field and drug companies. SELECTION CRITERIA: Randomised and quasi-randomised trials of artemisinin derivatives, alone or in combination with other antimalarials, compared with standard antimalarial treatments, in adults or children with uncomplicated falciparum malaria. Only trials where treatment was given by mouth or suppository were included. Comparisons between different artemisinin derivatives and treatment regimens were also included. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed and data were extracted independently by the two reviewers. MAIN RESULTS: Forty-one trials involving over 5000 patients were included. Variation in study design and quality made synthesis of the data problematic. Allocation concealment was adequate in only two trials. Most data were from areas of multidrug resistant falciparum malaria in South East Asia. Compared with standard antimalarial treatments, artemisinin drugs showed fast parasite clearance and high cure rates at follow-up, provided the duration of treatment with artemisinin drugs was adequate. Combination with mefloquine improved sustained parasite clearance and was effective in multidrug resistant areas. When doses were adequate, the combination shortened the duration of treatment. We found no evidence that artemisinin drugs are more harmful than standard treatment drugs over a typical trial period of 28 days. REVIEWER'S CONCLUSIONS: The evidence suggests that artemisinin drugs are effective and safe for treating uncomplicated malaria. There is no evidence from randomised trials that one artemisinin derivative is better than the others. In areas where there is mefloquine resistance, combination therapy with an artemisinin derivative appears to improve sustained parasite clearance compared with either drug alone.
Adult↗
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↗
Artemisinin derivatives for treating severe malaria.
BACKGROUND: Artemisinin derivatives may have advantages over quinoline drugs for treating severe malaria since they are fast acting and effective against quinine resistant malaria parasites. OBJECTIVES: The objective of this review was to assess the effects of artemisinin drugs for severe and complicated falciparum malaria in adults and children. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Science Citation Index, Lilacs, African Index Medicus, conference abstracts and reference lists of articles. We contacted organisations, researchers in the field and drug companies. SELECTION CRITERIA: Randomised and pseudo-randomised trials comparing artemisinin drugs (rectal, intramuscular or intravenous) with standard treatment, or comparisons between artemisinin derivatives in adults or children with severe or complicated falciparum malaria. DATA COLLECTION AND ANALYSIS: Eligibility, trial quality assessment and data extraction were done independently by two reviewers. Study authors were contacted for additional information. MAIN RESULTS: Twenty three trials are included, allocation concealment was adequate in nine. Sixteen trials compared artemisinin drugs with quinine in 2653 patients. Artemisinin drugs were associated with better survival (mortality odds ratio 0.61, 95% confidence interval 0.46 to 0.82, random effects model). In trials where concealment of allocation was adequate (2261 patients), this was barely statistically significant (odds ratio 0.72, 95% CI 0.54 to 0.96, random effects model). In 1939 patients with cerebral malaria, mortality was also lower with artemisinin drugs overall (odds ratio 0.63, 95% CI 0.44 to 0.88, random effects model). The difference was not significant however when only trials reporting adequate concealment of allocation were analysed (odds ratio 0.78, 95% CI 0.55 to 1.10, random effects model) based on 1607 patients. No difference in neurological sequelae was shown. Compared with quinine, artemisinin drugs showed faster parasite clearance from the blood and similar adverse effects. REVIEWER'S CONCLUSIONS: The evidence suggests that artemisinin drugs are no worse than quinine in preventing death in severe or complicated malaria. No artemisinin derivative appears to be better than the others.
Adult↗
Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids.
BACKGROUND: Uterine fibroids, smooth muscle tumours of the uterus, are found in at least 25 to 35% of women over the age of 35 years. Although some of these tumours are asymptomatic, up to 50% cause symptoms severe enough to warrant therapy and surgery is the standard treatment. Fibroid growth is stimulated by oestrogen and gonadotropin releasing hormone agonists (GnRHa) which induce a state of hypoestrogenism have been investigated as a potential treatment. GnRHa treatment causes fibroids to shrink but cannot be used long term because of unacceptable symptoms and bone loss. Therefore, GnRHa may be useful pre-operatively both to reduce fibroid and uterine volume and control bleeding. OBJECTIVES: The objective of this review is to evaluate the role of pre-treatment with gonadotropin releasing hormone (GnRH) analogues prior to a major surgical procedure, either hysterectomy or myomectomy, for uterine fibroids. 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. In most cases, the first author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of GnRH analogue treatment versus placebo, no treatment, or other medical therapy prior to surgery, either myomectomy or hysterectomy, for uterine fibroids. DATA COLLECTION AND ANALYSIS: Nineteen 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 twelve trials where GnRH analogue treatment was compared with no pre-treatment and five trials where GnRH analogue treatment was compared with placebo (two trials are awaiting assessment). No RCTs of GnRH analogue treatment versus other medical therapy were identified. Results from pre-operative outcomes were combined for both types of surgery but results from intra- and post-operative outcomes were reported separately for myomectomy and hysterectomy. Subgroup analysis was performed according to type of control group, no pre-treatment or placebo, and for some outcomes there were additional subgroup analyses according to size of the uterus in gestational weeks. MAIN RESULTS: Pre- and post-operative haemoglobin (Hb) and haematocrit (HCT) were significantly improved by GnRH analogue therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced. Pelvic symptoms were also reduced but some adverse events were more likely during GnRH analogue therapy. Hysterectomy appeared to be easier after pre-treatment with GnRH analogue therapy; there was reduced operating time and a greater proportion of hysterectomy patients were able to have a vaginal rather than an abdominal procedure. Duration of hospital stay was also reduced. Blood loss and rate of vertical incisions were reduced for both myomectomy and hysterectomy. Evidence of increased risk of fibroid recurrence after GnRH analogue pre-treatment in myomectomy patients was equivocal and no data were available to assess change in post-operative fertility. The increased costs associated with GnRH analogue therapy were not assessed. REVIEWER'S CONCLUSIONS: The use of GnRH analogues for 3 to 4 months prior to fibroid surgery reduce both uterine volume and fibroid size. They are beneficial in the correction of pre-operative iron deficiency anaemia, if present, and reduce intra-operative blood loss. If uterine size is such that a mid-line incision is planned, this can be avoided in many women with the use of GnRH analogues. For patients undergoing hysterectomy, a vaginal procedure is more like
Antineoplastic Agents, Hormonal↗
Cognitive behaviour therapy for adults with chronic fatigue syndrome.
OBJECTIVES: 1. To systematically review all randomised controlled trials of cognitive-behaviour therapy (CBT) for adults with chronic fatigue syndrome (CFS); 2. To test the hypothesis that CBT is more effective than orthodox medical management or other interventions in adults with CFS. SEARCH STRATEGY: 1. Electronic searching of bibliographic databases, including Medline, PsycLIT, Biological Abstracts, Embase, SIGLE, Index to Theses, Index to Scientific and Technical Proceedings, and Science Citation Index, using multiple search terms in order to perform a highly sensitive search. 2. Electronic searching of the Trials Register of the Depression, Anxiety and Neurosis group. 3. Citation lists of relevant studies and reviews were perused for other relevant trials. 4. Contact with the principal authors of relevant studies, and with researchers in the field. SELECTION CRITERIA: All randomised controlled trials were included in which - adult patients with CFS; - received CBT or a control intervention, being either orthodox medical management or another intervention; - and whose outcomes were assessed in an appropriate way. CBT could be either type 'A' (encouraging return to 'normal' levels of rest and activity) or type 'B' (encouraging rest and activity which were within levels imposed by the disorder). DATA COLLECTION AND ANALYSIS: The two reviewers worked independently throughout the selection of trials and data extraction, comparing findings only when there was disagreement. Relevant trials were allocated to one of three quality categories. Full data extraction, using a standardised data extraction sheet, was performed on studies which were of high or moderate quality. Trials of low quality were excluded from the review. The comparisons made to test the review hypothesis were of type 'A' CBT versus other intervention(s), and of type 'B' CBT versus other intervention(s). Functional outcome was used as the main outcome for comparison, but other appropriate outcomes were compared where possible. Results were synthesised using the Review Manager software. For dichotomous data, the odds ratio was calculated for each study. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. MAIN RESULTS: Only three relevant trials of adequate quality were found. These trials demonstrated that CBT significantly benefits physical functioning in adult out-patients with CFS when compared to orthodox medical management or relaxation. It is necessary to treat about two patients to prevent one additional unsatisfactory physical outcome about six months after treatment end. CBT appeared highly acceptable to the patients in these trials. There is no satisfactory evidence for the effectiveness of CBT in patients with the milder forms of CFS found in primary care or in patients who are so disabled that they are unable to attend out-patients. Additionally, there is no satisfactory evidence for the effectiveness of group CBT. REVIEWER'S CONCLUSIONS: Cognitive behaviour therapy appears to be an effective and acceptable treatment for adult out-patients with chronic fatigue syndrome. CFS is a common and disabling disorder. Its sufferers deserve the medical profession to be more aware of the potential of this therapy to bring lasting functional benefit, and health service managers to increase its availability. Further research is needed in this important area. Trials should conform to accepted standards of reporting and methodology. The effectiveness of CBT in more and less severely disabled patients than those usually seen in out-patient clinics needs to be assessed. Trials of group CBT and in-patient CBT compared to orthodox medical management, and of CBT compared to graded activity alone, also need to be conducted.
Adult↗
Diazepam for treating tetanus.
BACKGROUND: Clinical management of the muscle spasms and rigidity of tetanus poses a difficult therapeutic problem to physicians everywhere, especially in resource poor countries. There are wide variations in therapeutic regimens commonly used in clinical practice due to uncertainties about effectiveness of conventional drugs. Diazepam compared to other drugs (eg phenobarbitone and chlorpromazine) may have advantages because of combined anticonvulsant, muscle relaxant, sedative and anxiolytic effects. OBJECTIVES: To compare diazepam to other drugs in treating the muscle spasms and rigidity of tetanus in children and adults. SEARCH STRATEGY: We searched the Cochrane Neonatal Group trials register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (1980 to October 2003), LILACS (2003), CINAHL (October 2003), Science Citation Index, African Index Medicus, conference abstracts and reference lists of articles. We contacted researchers, experts and organizations working in the field and used personal communication. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials. DATA COLLECTION AND ANALYSIS: We independently identified eligible trials, assessed trial methodological quality and extracted data. MAIN RESULTS: Two studies met the inclusion criteria. Method of generation of allocation sequence, concealment of allocation and blinding were unclear in both studies. A total of 134 children were allocated to three treatment groups comprising diazepam alone, phenobarbitone and chlorpromazine, or phenobarbitone and chlorpromazine and diazepam.Meta-analysis of in-hospital deaths indicates that children treated with diazepam alone had a better chance of survival than those treated with combination of phenobarbitone and chlorpromazine (Relative Risk for death 0.36; 95% confidence interval 0.15 to 0.86; Risk Difference -0.22; 95% CI -0.38 to -0.06). Giving diazepam alone, or supplementing conventional anticonvulsants (phenobarbitone and chlorpromazine) with diazepam, was reported in one study to be associated with a statistically significantly milder clinical course and shorter duration of hospitalization. REVIEWER'S CONCLUSIONS: Although there is evidence that diazepam alone compared with combination of phenobarbitone and chlorpromazine is more effective in treating tetanus, the small size, methodological limitations and lack of data on drug safety from available trials preclude definite conclusions to support change in current clinical practice. The application of the present evidence should be moderated by local needs and circumstances, pending the availability of more evidence. We recommend a large multicenter, randomized controlled trial which compares diazepam alone with combinations of other drugs (excluding diazepam).
Anticonvulsants↗
Progressive resistive exercise interventions for adults living with HIV/AIDS.
BACKGROUND: Due to medical advancements, many people living with HIV infection in developed countries are living longer (Palella 1998). HIV infection can now present as a chronic illness with an uncertain natural disease history. The changing course of HIV infection has lead to a potential increase in the prevalence and impact of disability in people living with HIV infection. Exercise is one key management strategy used by health care professionals to address impairments (problems with body function or structure as a significant deviation or loss such as pain or weakness), activity limitations (difficulties an individual may have in executing activities such as inability to walk) and participation restrictions (problems an individual may experience in life situations such as inability to work) in this population (World Health Organization 2001). Exercise may also be used to address unwanted changes in weight and body composition in people living with HIV infection. Aerobic exercise has been associated with improvements in strength, cardiovascular function, and psychological status in general populations (Bouchard 1993). Results of a systematic review suggested that aerobic exercise interventions appeared to be safe and may lead to improvements in cardiopulmonary fitness for adults living with HIV/AIDS (Nixon 2002). But what are the effects of progressive resistive exercise (PRE) for adults living with HIV infection?A better understanding of the effectiveness and safety of progressive resistive exercise will enable people living with HIV and their health care workers to practice effective and appropriate exercise prescription, thus contributing to improved overall outcomes for adults living with HIV infection. OBJECTIVES: To examine the safety and effectiveness of progressive resistive exercise interventions on weight, body composition, strength, immunological/virological, cardiopulmonary and psychological parameters in adults living with HIV infection. SEARCH STRATEGY: To identify studies to be included in this review, we searched the following databases: MEDLINE, EMBASE, CINAHL, COCHRANE, SCIENCE CITATION INDEX, PSYCHINFO, SOCIOLOGICAL ABSTRACTS, SSCI, ERIC, DAI and HEALTHSTAR. We also reviewed both published and unpublished abstracts and proceedings from major international and national HIV/AIDS conferences such as the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), the Conference on Retroviruses and Opportunistic Infections (CROI), the Infectious Diseases Society of America Conference (IDSA), and the International AIDS Conference (IAC). Reference lists from pertinent articles and books were reviewed, as well as Collaborative Review Group databases. Targeted journals were also hand searched for relevant articles. No language restriction was applied. The search strategy covered literature from 1980-August 2003. SELECTION CRITERIA: We included studies that were randomized controlled trials (RCTs) comparing progressive resistive exercise interventions with no progressive resistive exercise or another exercise or treatment modality, performed at least three times per week, and lasting at least four weeks among adults (18 years of age or older) living with HIV/AIDS. DATA COLLECTION AND ANALYSIS: Data collection forms were used by reviewers to abstract data pertaining to study design, participants, interventions, outcomes and methodological quality from the studies that met inclusion criteria. Whenever possible, meta-analyses were conducted on outcomes using RevMan 4.2.2 computer software. MAIN RESULTS: Seven studies met the inclusion criteria for this systematic review. Meta-analysis was limited due to the following differences among the studies: types of exercise interventions, inclusion of co-intervention groups, level of exercise supervision, baseline body composition and testosterone levels of participants, types of outcomes assessed, and methodological quality of the individual studies.Main results indicated that performing progressive resistive exercise or a combination of progressive resistive exercise and aerobic exercise at least three times a week for at least four weeks appears to be safe and may lead to statistically and possibly clinically important increases in body weight and composition. Results also indicate exercise interventions may lead to clinically important improvements in cardiopulmonary fitness. Individual studies included in this review suggest that progressive resistive exercise interventions with or without aerobic exercise also contribute to improvements in strength and psychological status for adults living with HIV/AIDS. Individual studies indicate that progressive resistive exercise or a combination of progressive resistive and aerobic exercise appears to be safe for adults living with HIV/AIDS who are medically stable as a result of no change seen in immunological/virological status. These results are limited to those who continued to exercise and for whom there were adequate follow-up data. REVIEWERS' CONCLUSIONS: Progressive resistive exercise or a combination of progressive resistive exercise and aerobic exercise appear to be safe and may be beneficial for adults living with HIV/AIDS. These findings are limited by the small number of studies that could be included in meta-analyses, small sample sizes and variable participant withdrawal rates among included studies. Future research would benefit from including participants at various stages of HIV infection, a greater proportion of female participants, and participants in a variety of age groups to increase the generalizability of results. Furthermore, future research would benefit from studies with larger sample sizes that conduct an "intention-to-treat" analysis (analysis of participants based on the groups to which they were originally allocated) to better understand outcomes of participants that withdraw from exercise interventions.
Acquired Immunodeficiency Syndrome↗
Effect of beta-blockade on the interpretation of the exercise ECG: ST level versus delta ST/HR index.
The diagnostic value of exercise-induced ST segment depression is considered to be decreased in patients receiving beta-blockers. One approach to improving predictive accuracy has been to use the ratio of maximal change in exercise-induced ST segment depression to the corresponding maximal change in heart rate (delta ST/HR index). The present study compared these two ECG methods. The records of exercise tests performed on 3047 male veterans were screened to exclude patients with prior revascularization procedures or myocardial infarction, those receiving digoxin, and those with certain resting ECG abnormalities; the use of beta-blocker drugs at the time of testing was also noted. All exercise tests were sign/symptom limited. Significant angiographic coronary disease was defined as greater than or equal to 75% reduction in luminal diameter of at least one coronary artery. Disease severity was evaluated in an expanded study group that included patients with prior myocardial infarction. Mean maximal heart rate was 21 beats.min-1 lower for those receiving beta-blockers (p less than 0.05), but there was no difference in mean metabolic equivalent (MET) level achieved. The diagnostic accuracy of an abnormal test result for determination of the presence or absence of coronary artery disease was not significantly different in the subgroup taking beta-blockers versus the subgroup not taking beta-blockers (N = 200), and use of the delta ST/HR index did not improve test performance. For discrimination of severe disease, test accuracy was also unaffected by beta-blockers and was not improved by the delta ST/HR index (N = 454).(ABSTRACT TRUNCATED AT 250 WORDS)
Adrenergic beta-Antagonists↗