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Cytochrome p450 enzymes mechanism based inhibitors: common sub-structures and reactivity.

The inhibition of human cytochrome P450s (CYPs) is one of the most common mechanisms which can lead to drug-drug interactions. The inhibition of CYPs can be reversible (competitive or non-competitive) or irreversible. Irreversible inhibition usually derives from activation of a drug by CYPs into a reactive metabolite, which tightly binds to the enzyme active site, leading to a long lasting inactivation. This process is called "mechanism based inhibition" or "suicide inhibition". The irreversible inactivation usually implies the formation of a covalent bond between the metabolite and the enzyme, which can lead to hapten formation and can in some cases trigger an autoimmune-response. For these reasons it is of utmost importance to study the mechanism of the CYP inhibition of new potential drugs as early as possible during the drug discovery process. The literature on CYPs is vast and covers numerous aspects of their biology and biochemistry, however to our knowledge there is no general and systematic review focusing on mechanism-based inhibitors; we have reviewed the literature and compiled all the available data on chemical entities, which are known to be CYP suicide inhibitors. Each compound is reported together with its chemical structure, the CYP isoform and the parameters describing the inactivation. Literature references are reported together with their PMID (PubMed ID number) to allow a fast retrieval of the papers. This review offers a quick reference to help predict liabilities of new chemical entities without carrying out extensive in vitro work, and will hopefully help in designing safer drugs.

Cytochrome P-450 Enzyme Inhibitors↗

Lumbar supports for prevention and treatment of low back pain.

BACKGROUND: Lumbar supports are used in the treatment of low back pain patients to make the impairment and disability vanish or decrease. Lumbar supports are also used to prevent the onset of low back pain (primary prevention) or to prevent recurrences of a low back pain episode (secondary prevention). OBJECTIVES: The objective of this systematic review was to assess the effects of lumbar supports for prevention and treatment of non-specific low back pain. SEARCH STRATEGY: We searched the Medline, Cinahl and Current Contents databases and the Cochrane Controlled Trials Register up to September 1999, and the Embase database up to September 1998. We also screened references given in relevant reviews and identified controlled trials, and used Science Citation Index to identify additional controlled trials. SELECTION CRITERIA: Controlled clinical trials that reported on any type of lumbar supports as preventive or therapeutic intervention for non-specific low back pain were included. DATA COLLECTION AND ANALYSIS: One reviewer extracted data from the trials considering characteristics of the study population, characteristics of the interventions and the final results for each outcome measure. The reviewer compared these findings to data regarding the same characteristics of the same studies published already in other reviews. The methodological quality was independently assessed by two reviewers. Because it was not possible to perform a quantitative analysis, a qualitative meta-analysis was performed in which the strength of evidence on the effectiveness of lumbar supports was classified as being strong, moderate, limited or conflicting, and no evidence. MAIN RESULTS: Five randomized and two nonrandomized controlled preventive trials and six randomized therapeutic trials were included in our review. Overall the methodological quality of the studies included in our review was rather low. Only four of the thirteen studies scored positive on 50% or more of the the internal validity items. There was moderate evidence that for primary prevention lumbar supports are not more effective than other types of treatment or no intervention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, while it is still unclear if lumbar supports are more effective than other interventions for treatment of low back pain. REVIEWER'S CONCLUSIONS: There is still a need for high quality randomised trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realisation of an adequate compliance.

Braces↗

Oestrogens alone or with amniotomy for cervical ripening or induction of labour.

BACKGROUND: Studies in sheep showed that there is a pre-labour rise in oestrogen and a decrease in progesterone, both of these changes stimulate prostaglandin production and may help initiate labour. Though oestrogen has been suggested as an effective cervical ripening or induction agent, research in humans have failed to demonstrate a similar physiological mechanism. The use of oestrogen as an induction agent is not currently common practice, as such this systematic review should be regarded as an historical review. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology. OBJECTIVES: To determine, from the best available evidence, the effectiveness and safety of oestrogens alone or with amniotomy for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: April 2001. SELECTION CRITERIA: (1) randomised controlled trials comparing oestrogens alone used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally. MAIN RESULTS: When comparing oestrogen with placebo there was no difference between the rate of caesarean section (7.1% versus 10.3%, relative risk (RR) 0.70, 95% confidence interval (CI) 0.30,1.62). There were no differences between rates of uterine hyperstimulation with or without fetal heart rate changes or instrumental vaginal delivery. None of the studies reported the rates of either vaginal delivery not achieved in 24 hours, or cervix unfavourable/unchanged after 12-24 hours. There were insufficient data to make any meaningful conclusions when comparing oestrogen with vaginal PGE2, intracervical PGE2, oxytocin alone or extra amniotic PGF2a, as to whether oestrogen is effective in inducing labour. REVIEWER'S CONCLUSIONS: There were insufficient data to draw any conclusions regarding the efficacy of oestrogen as an induction agent.

Amnion↗

Chinese medicinal herbs for acute bronchitis.

BACKGROUND: Acute bronchitis is one of the most common diagnoses made by primary-care physicians. It is traditionally treated with antibiotics, (although the evidence for their effectiveness is weak and modest at best), and other even less effective treatments. Chinese medicinal herbs have been also used as treatment. OBJECTIVES: This review aims to summarise the existing evidence on the comparative effectiveness and safety of Chinese medicinal herbs for treating uncomplicated acute bronchitis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), which includes the Cochrane Acute Respiratory Infections Group's specialised register; The Chinese Cochrane Centre's Controlled Trials Register (up to December 2004); MEDLINE (1966 to March Week 1, 2005); EMBASE (1988 to December 2004); and the Chinese Biomedical Database (CBM) (1980 to December 2004). SELECTION CRITERIA: Randomised controlled trials comparing Chinese medicinal herbs with placebo, antibiotics or other Western medicines for the treatment of uncomplicated acute bronchitis. DATA COLLECTION AND ANALYSIS: At least two authors extracted data and assessed trial quality. MAIN RESULTS: Four trials reported the time to improvement of cough, fever, and rales associated with bronchitis and showed that patients treated with Chinese herbs had a shorter duration of signs and symptoms. Two trials reported the proportion of patients with improved signs and symptoms at follow up and showed that Chinese herbs were beneficial in terms of relief of signs and symptoms. Thirteen trials analysed the data on physician global assessment of improvement at follow up. Nine of thirteen trials showed that Chinese herbs were superior to routine treatment and the other four trials showed a similar effect to routine treatment. In general, Chinese herbs appeared beneficial. Only one trial reported on adverse effects during treatment. AUTHORS' CONCLUSIONS: There is insufficient quality data to recommend the routine use of Chinese herbs for acute bronchitis. The benefit found in this systematic review could be due to publication bias and study-design limitations of the individual studies. In addition, the safety of Chinese herbs is unknown due to the lack of toxicological evidence on these Chinese herbs, though adverse events are rarely reported. Chinese herbs should be used carefully.

Acute Disease↗

[Do hip protectors decrease the risk of hip fracture in elderly?].

Efforts aimed at preventing hip fractures include lifestyle advice for high-risk elderly, interventions to reduce the risk of falls and medication for osteoporosis. Alternative approach is the use of hip protectors. Hip protectors have pads designed to cover the greater trochanter and attenuate or disperse the force of a fall sufficiently to prevent a hip fracture. There are 14 randomized controlled trials (RCTs) included in the Cochrane systematic review until 2005. All RCTs were classified into three groups by the type of randomization; cluster randomized in institutions, individually randomized in institutions and individually randomized in community. There is little evidence to support the use of hip protectors outside the nursing home setting. Further research is required, primarily to produce a device that provide higher compliance, and which will then need to be tested in another RCT.

Aged↗

General versus spinal/epidural anaesthesia for surgery for hip fractures in adults.

BACKGROUND: The majority of hip fracture patients are treated surgically, requiring anaesthesia. OBJECTIVES: To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. This is primarily regional (spinal or epidural) anaesthesia versus inhalation general anaesthesia, but also includes ketamine anaesthesia versus inhalation general anaesthesia. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, selected orthopaedic and anaesthetic journals and conference proceedings, and reference lists of relevant articles. Date of the most recent search: August 1998. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in skeletally mature persons. Trials comparing the use of local nerve blocks are not considered in this review. Neither are trials using different types of drugs or techniques with one type of anaesthesia. The primary outcome was mortality. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a nine item scale, and extracted data. The other two reviewers independently checked these results. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Fifteen trials, involving 2162 patients, which compared regional anaesthesia with general anaesthesia, were included. All trials had methodological flaws. Regional anaesthesia was associated with a decreased mortality at one month (49/766 (6.4%) versus 76/812 (9.4%)) of borderline statistical significance (Peto odds ratio 0.66, 95% confidence interval 0.46 to 0.96)). The results for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), Peto odds ratio 0.91, 95% confidence interval 0.67 to 1.24). The reduced numbers at one year, coming exclusively from two studies, preclude any useful conclusions for long term mortality (80/354 (22.6%) versus 78/372 (21.0%), Peto odds ratio 1.10, 95% confidence interval 0.77 to 1.57). Regional anaesthesia was associated with a tendency to a longer operation (weighted mean difference 4.8 minutes, 95% confidence interval 1.1 to 8.6 minutes), and a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/37(76%); Peto odds ratio 0. 41, 95% confidence interval 0.23 to 0.72), although this conclusion is insecure due to possible selection bias in the subgroups in whom this outcome was measured. No other statistically significant differences in outcome were identified. There was insufficient evidence to draw any conclusions from a further two included trials, involving a total of 100 patients, which compared other types of anaesthesia. REVIEWER'S CONCLUSIONS: Regional anaesthesia and general anaesthesia appear to produce comparable results for most of the outcomes studied. Regional anaesthesia may reduce short-term mortality but no conclusions can be drawn for longer term mortality.

Adult↗

Magnesium sulphate versus diazepam for eclampsia.

BACKGROUND: Eclampsia, the occurrence of a convulsion in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants are used to control eclamptic fits and to prevent further fits. OBJECTIVES: The objective of this review was to assess the effects of magnesium sulphate compared with diazepam when used for the care of women with eclampsia. Magnesium sulphate is compared with phenytoin and with lytic cocktail in other Cochrane reviews. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth trials register (28 November 2002) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002). SELECTION CRITERIA: Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with diazepam for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS: Both reviewers assessed and extracted data. MAIN RESULTS: Seven trials involving 1441 women are included. Most of the data are from trials of good quality. Magnesium sulphate is associated with a reduction in maternal death when compared to diazepam (six trials 1336 women; relative risk (RR) 0.59, 95% confidence interval (CI) 0.37 to 0.94). There is also a substantial reduction in the risk recurrence of further fits (seven trials 1441 women; RR 0.44, 95% CI 0.34 to 0.57). There were few differences in any other measures of outcome, except for fewer Apgar scores less than seven at five minutes (two trials 597 babies; RR 0.72, 95% CI 0.55 to 0.94) and fewer babies with a length of stay in special care baby unit more than seven days (three trials 631 babies; RR 0.66, 95% CI 0.46 to 0.95) associated with magnesium sulphate. REVIEWER'S CONCLUSIONS: Magnesium sulphate appears to be substantially more effective than diazepam for treatment of eclampsia.

Anticonvulsants↗

Organised inpatient (stroke unit) care for stroke.

BACKGROUND: Specially organised stroke units can be a ward or team that exclusively manages stroke patients (a dedicated stroke unit) or a ward or team that provides a generic disability service (a mixed assessment or rehabilitation unit). OBJECTIVES: The objective of this review was to assess the effect of care in a stroke unit compared with conventional care of patients following a stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, reference lists of articles and contacted researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing organised inpatient stroke unit care with conventional care. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and trial quality. The principal reviewer conducted a structured interview with the coordinators of unpublished trials. MAIN RESULTS: Twenty trials were included. Stroke unit care showed a reduction in the odds of death recorded at final follow-up (median one year). The odds ratio was 0.83, 95% confidence interval 0.71 to 0.97. The odds of death or institutionalised care were lower (0.76, 95% confidence interval 0.65 to 0.90) as were death or dependency at final review (odds ratio 0.75, 95% confidence interval 0.65 to 0.87). Subgroup analyses showed that the observed benefits were independent of patient age, sex, stroke severity, and types of stroke unit organisation. There was no indication that organised stroke unit care resulted in increased hospital stay, although there was heterogeneity between the trials. REVIEWER'S CONCLUSIONS: Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits are not restricted to any particular sub-group of patients or model of stroke unit care. No systematic increase was observed in the length of inpatient stay.

Hospital Units↗

Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term.

BACKGROUND: On the basis of evidence from non-randomised studies, it has been recommended that all babies born through thick meconium should have their tracheas intubated so that suctioning of their airways can be performed. The aim is to reduce the incidence and severity of meconium aspiration syndrome. However, for term babies who are vigorous at birth endotracheal intubation may be both difficult and unnecessary. OBJECTIVES: To determine if endotracheal intubation and suction of the airways at birth in vigorous term meconium-stained babies is more beneficial than routine resuscitation including aspiration of the oro-pharynx. SEARCH STRATEGY: The search was made from Oxford Database of Perinatal Trials, the Neonatal Trials Registry of the Cochrane Neonatal Collaborative Review Group and information obtained from knowledgeable practising neonatologists. SELECTION CRITERIA: Randomised trials which compared a policy of routine vs no (or selective) use of endotracheal intubation and aspiration in the immediate management of vigorous term meconium-stained babies at birth. DATA COLLECTION AND ANALYSIS: Data regarding clinical outcomes including mortality, meconium aspiration syndrome, other respiratory conditions, pneumothorax, need for oxygen supplementation, stridor, convulsions and hypoxic-ischaemic encephalopathy were abstracted and analysed using Revman 3.1.1. MAIN RESULTS: Four randomised controlled trials of endotracheal intubation at birth in vigorous term meconium-stained babies were identified. Meta-analysis of these trials does not support routine use of endotracheal intubation at birth in vigorous meconium-stained babies to reduce mortality, meconium aspiration syndrome, other respiratory symptoms or disorders, pneumothorax, oxygen need, stridor, HIE and convulsions. REVIEWER'S CONCLUSIONS: Routine endotracheal intubation at birth in vigorous term meconium-stained babies has not been shown to be superior to routine resuscitation including oro-pharyngeal suction. This procedure cannot be recommended for vigorous infants until more research is available.

Humans↗

Individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness.

BACKGROUND: People with schizophrenia and severe mental illness may need much support from health care professionals, in most cases over a long period of time. Research on the effects of psychotherapy for schizophrenia shows mixed results. Although pharmacological interventions remain the treatment of choice for schizophrenia patients, it is also of interest to look at the effects of treatment methods focusing on psychosocial factors affecting schizophrenia. OBJECTIVES: To review the effects of individual psychodynamic psychotherapy and/or psychoanalysis for people with schizophrenia or severe mental illness. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1985-1999), CINAHL (1982-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (1999), Dissertation Abstracts On disc (1866-1999), EMBASE (1980-1999), MEDLINE (1966-1999), PsycLIT (1974-1999), and Sociofile (1974-1998) were made. Authors of included trials were contacted for information on further trials. SELECTION CRITERIA: All randomised trials of individual psychodynamic psychotherapy or psychoanalysis for people with schizophrenia or severe mental illness (however defined) were selected. DATA COLLECTION AND ANALYSIS: Data were independently extracted by at least two reviewers. For dichotomous data relative risks (RR) were calculated and for continuous data weighted mean differences (WMD) between groups were calculated. MAIN RESULTS: No trials of a psychoanalytic approach were identified. Data are sparse for all comparisons involving a psychodynamic approach. There is no evidence of any positive effect of psychodynamic therapy and the possibility of adverse effects seems never to have been considered. The psychodynamic approach may be more acceptable to people than a more cognitive reality-adaptive therapy. REVIEWER'S CONCLUSIONS: Current data do not support the use of psychodynamic psychotherapy techniques for hospitalised people with schizophrenia. If psychoanalytic therapy is being used for people with schizophrenia there is an urgent need for trials.

Humans↗

Colchicine for alcoholic and non-alcoholic liver fibrosis and cirrhosis.

BACKGROUND: The majority of liver fibrosis and liver cirrhosis cases in the Western World is caused by alcohol and hepatotoxic viruses. Colchicine is an anti-inflammatory and anti-fibrotic medication. Several randomised clinical trials have addressed the question whether colchicine has any efficacy in patients with alcoholic as well as non-alcoholic fibrosis and cirrhosis. OBJECTIVES: The objectives were to assess the efficacy of colchicine on mortality, clinical symptoms and complications, liver biochemistry, liver fibrosis markers, liver histology, alcohol consumption, quality of life, and health economics in patients with alcoholic and non-alcoholic fibrosis or cirrhosis, excluding primary biliary cirrhosis and other rarer forms of fibrosis/cirrhosis. Also adverse events were assessed. SEARCH STRATEGY: The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, and full text searches were combined. SELECTION CRITERIA: Only randomised clinical trials were included studying patients with alcoholic fibrosis, alcoholic hepatitis and/or alcoholic cirrhosis as well as patients with viral induced or cryptogenic fibrosis and/or cirrhosis according to the diagnostic work-up of the individual trial. Interventions encompassed peroral colchicine at any dose versus placebo or no intervention. The trials could be double-blind, single-blind or unblinded. The trials could be unpublished or published and no language limitations were applied. DATA COLLECTION AND ANALYSIS: All analyses were performed according to the intention-to-treat method. The statistical package (RevMan and MetaView) provided by the Cochrane Collaboration was used. The methodological quality of the randomised clinical trials was evaluated by the Jadad-scale. MAIN RESULTS: Combining the results of 14 randomised clinical trials including 1150 patients demonstrated no significant effects of colchicine on mortality (Peto odds ratio (OR) 0.90, 95% confidence interval (CI) 0.63 to 1.29), liver related mortality (OR 1.05, 95% CI 0.61 to 1.80), complications (OR 1.01, 95% CI 0.63 to 1.62), liver biochemistry, liver histology, and alcohol consumption (OR 1.02, 95% CI 0.58 to 1.79). Colchicine was associated with a significantly increased risk of adverse events (OR 4.92, 95% CI 2.66 to 9.10; P< 0.001). REVIEWER'S CONCLUSIONS: Colchicine should not be used for alcoholic, viral, or cryptogenic liver fibrosis or liver cirrhosis outside randomised trials.

Colchicine↗

Patient education for mechanical neck disorders.

BACKGROUND: To track down the best estimate of efficacy of the various conservative management strategies for mechanical neck disorders, a four-part systematic review was prepared. Part four investigates the efficacy of patient education strategies as the therapeutic intervention. OBJECTIVES: This review of patient education is one of four reviews of conservative management of mechanical neck disorders. The other reviews address manual, physical and drug therapies. The objective of this review was to assess the effects of patient education for pain in adults with mechanical neck disorders. SEARCH STRATEGY: We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services from 1985 to December 1993, reference lists of the retrieved articles and we contacted experts in the field. SELECTION CRITERIA: Randomised trials or controlled clinical trials of patient educational strategies for adults with mechanical neck disorders. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain data that could not be found in the published reports. MAIN RESULTS: Three trials were included. Their methodological quality varied from weak to strong. One trial did not find a significant reduction in pain using group instructional strategies (neck school) and exercise with or without psychological counselling compared to no treatment (standardised mean difference 0.07, 95% confidence interval -0.51 to 0.66, and -0.37, 95% confidence interval -0.95 to 0.22, respectively). Another trial did not find a significant reduction in pain using individualised patient education (advice), anti-inflammatories and analgesics compared with placebo (standardised mean difference 0.24, 95% confidence interval -0.58 to 1.07). The third trial found that advice which included demonstrated mobilization exercises, verbal and written instruction on posture correction, the use of a collar, heat sources, muscle relaxation and analgesics gave significant pain relief compared with general advice about mobilisation after a period of rest and use of analgesics at 4 weeks of treatment (standardised mean difference -0.62, 95% confidence interval -1.05 to -0.19) but at 6 weeks of treatment there was no longer any difference (s.m.d. -0.37, 95% confidence interval -0.8 to 0.05). The first two trials lacked statistical power and the third was methodologically weak. REVIEWER'S CONCLUSIONS: Patient education utilising individualised or group instructional strategies has not been shown to be beneficial in reducing pain for mechanical neck disorders.

Adult↗

Exercise for female osteoporosis. A systematic review of randomised clinical trials.

The treatment and prevention of osteoporosis in women represents an unresolved problem. The aim of this systematic review was to determine whether exercise can be useful in this context. Various literature searches identified 21 randomised controlled trials on the subject. These are highly diverse in more than one respect. Collectively, however, the strongly suggest that regular physical exercise can reduce the risk of osteoporosis and delay the physiological decrease of bone mineral density. It is concluded that regular exercise for women of practically all ages is well advised.

Bone Density↗

Colloid solutions for fluid resuscitation.

BACKGROUND: Colloids are widely used in the replacement of fluid volume, however doubts remain as to their benefits. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES: To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH STRATEGY: The Cochrane Injuries Group specialised register, The Cochrane Controlled trials register (all years), MEDLINE (1994-98), EMBASE (1974-98) were searched. Bibliographies of trials retrieved were searched and drug companies manufacturing colloids were contacted for information. SELECTION CRITERIA: Randomised and quasi randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The main outcomes measured were death, amount of whole blood transfused and incidence of adverse reactions. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS: 46 trials met the inclusion criteria, with a total of 2884 participants. Many of the trials were small. In the majority of trials quality was poor or uncertain. Deaths were obtained from 27 trials. Twenty three trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Thirteen trials recorded adverse reactions, but none occurred. For albumin or PPF versus hydroxyethyl starch (HES) 20 trials reported mortality. The pooled relative risk (RR) was 1.17 (95% CI 0.91, 1.50). For albumin or PPF versus gelatin 3 trials reported mortality. The RR was 0.99 (0.69, 1.42). For gelatin vs HES 3 trials reported mortality, RR was 0.97 (0.65, 1.44). RR was not estimable in the albumin vs dextran, gelatin vs dextran, and HES vs dextran groups. REVIEWER'S CONCLUSIONS: From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Blood Proteins↗

A descriptive study of randomized trials of treatments for childhood acute lymphoblastic leukaemia.

This report presents a historical and descriptive account of randomized trials in childhood leukaemia since the earliest such studies in the 1960s. It focuses on trials that began before 1988, making use of the register of trials developed for a systematic review of treatments for acute lymphoblastic leukaemia in children. The number of randomized trials starting each year increased from one or two in the 1960s to an annual average of five or six in the 1980s. However trials remained relatively small, with more than half of all randomizations accruing less than 200 patients and only five having more than 1000. Most trials were published more than once.

Adolescent↗

Nitrous oxide for relief of labor pain: a systematic review.

A systematic review was conducted to determine the efficacy and safety of nitrous oxide for labor analgesia. Eleven randomized controlled trials with adequate control groups and outcome assessment by parturients during or shortly after the intervention were used to determine efficacy. To determine adverse outcome, descriptions found in 8 controlled trials and in 8 observational studies were included. A nonsystematic review of studies on occupational exposure was also conducted. Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women.

Administration, Inhalation↗

Carbamazepine versus phenytoin monotherapy for epilepsy.

BACKGROUND: Worldwide, carbamazepine and phenytoin are commonly used antiepileptic drugs. This review summarizes evidence from randomized controlled trials in which these two drugs have been compared. OBJECTIVES: To review the best evidence comparing carbamazepine and phenytoin when used as monotherapy in subjects with partial onset seizures, or generalized onset tonic-clonic seizures with or without other generalized seizure types. SEARCH STRATEGY: We searched: (a) the trial register of the Cochrane Epilepsy Group; (b) The Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001); (c) MEDLINE 1966-2001. In addition we hand searched relevant journals and contacted the pharmaceutical industry and researchers in the field to seek any ongoing or unpublished studies. SELECTION CRITERIA: Randomized controlled trials in children or adults with partial onset seizures or generalized onset tonic-clonic seizures. Trials must have included a comparison of carbamazepine monotherapy with phenytoin monotherapy. DATA COLLECTION AND ANALYSIS: This was an individual patient data review. Outcomes were time to (a) withdrawal of allocated treatment, (b) 12 month remission, (c) six month remission, and (d) first seizure post randomization. Data were analysed using a stratified logrank analysis with results expressed as hazard ratios (HR) and 95% confidence intervals (95% CI), where a HR>1 indicates an event is more likely on phenytoin. MAIN RESULTS: Individual patient data are available for 551 participants from three trials, representing 63% of the participants recruited into the nine trials that met our inclusion criteria. By convention, for the outcomes time to six and 12 month remission HR>1 indicates a clinical advantage for phenytoin, whilst for time to withdrawal and first seizure HR>1 indicates a clinical advantage for carbamazepine. Results (HR (95% CI)) were: (i) time to withdrawal of allocated treatment 0.97(0.74 to 1.28), (ii) time to 12 month remission 1.00(0.78 to 1.29), (iii) time to six month remission 1.10(0.87 to 1.39), (iv) time to first seizure 0.91(0.74 to 1.12). The results suggest no overall difference between carbamazepine and phenytoin for these outcomes. REVIEWER'S CONCLUSIONS: We have not found evidence that a significant difference exists between carbamazepine and phenytoin for the outcomes examined in this review. Confidence intervals are wide and the possibility of important differences existing has not been excluded.

Anticonvulsants↗

Ivermectin for onchocercal eye disease (river blindness).

BACKGROUND: It is believed that ivermectin (a microfilaricide) could prevent blindness due to onchocerciasis. However, when given to everyone in communities where onchocerciasis is common, the effects of ivermectin on lesions affecting the eye are uncertain and data on whether the drug prevents visual loss is unclear. OBJECTIVES: The aim of this review is to assess the effectiveness of ivermectin in preventing visual acuity and visual field loss in onchocercal eye disease. The secondary aim is to assess the effects of ivermectin on lesions affecting the eye in onchocerciasis. SEARCH STRATEGY: We searched the Cochrane Eyes and Vision Group specialised register, the Cochrane Controlled Trials Register - CENTRAL, MEDLINE, EMBASE, the reference lists of identified trials, the Science Citation Index and we contacted investigators, experts and pharmaceutical companies to identify additional trials. SELECTION CRITERIA: We included randomised controlled trials with at least one year follow up, comparing ivermectin at a dose of 150 micrograms per kilogram of body weight with either placebo or no treatment. Participants were people normally resident in endemic onchocercal communities with or without one or more characteristic signs of ocular onchocerciasis. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. Study authors were contacted for additional information. Trials varied in design and setting, so no meta-analysis was done. MAIN RESULTS: This review includes five trials with data from 3810 participants. All the trials compared ivermectin with placebo and were judged to be of moderate risk of bias in terms of methodological quality. No statistically significant difference was observed in any trial (reporting visual acuity outcome) between ivermectin and placebo groups for visual acuity loss. REVIEWER'S CONCLUSIONS: Questions about the effectiveness of ivermectin in preventing visual acuity loss have not been answered by best available evidence.

Anthelmintics↗