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PubMed2005

Home-like versus conventional institutional settings for birth.

BACKGROUND: Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth. OBJECTIVES: Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings. SELECTION CRITERIA: All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to conventional hospital care. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals. MAIN RESULTS: Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models. AUTHORS' CONCLUSIONS: When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.

Birthing Centers↗
PubMed2000

Angioplasty (versus non surgical management) for intermittent claudication.

BACKGROUND: Intermittent claudication is pain in the legs due to muscle ischaemia associated with arterial stenosis or occlusion. Angioplasty is a technique that involves dilatation and recanalisation of a stenosed or occluded artery. OBJECTIVES: The objective of this review was to determine the effects of angioplasty of arteries in the leg when compared with non surgical therapy, or no therapy, for patients with mild to moderate intermittent claudication. SEARCH STRATEGY: The reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register and reference lists of relevant articles. The reviewers also contacted investigators in the field and hand searched recent conference proceedings. SELECTION CRITERIA: Randomised trials of angioplasty for mild or moderate intermittent claudication. DATA COLLECTION AND ANALYSIS: One reviewer extracted data and both reviewers assessed trial quality independently. MAIN RESULTS: Two trials with a total of 98 participants were included. The average age was 62 years old with 20 women and 789 men. Patients were followed for 15 months in one trial and six years in another. At six months of follow up, mean ankle brachial pressure indices were higher in the angioplasty groups than control groups (weighted mean difference 0.17, 95% confidence interval 0.11 to 0.24). In one trial, walking distances were greater in the angioplasty group, but in the other trial, in which controls underwent an exercise programme, walking distances did not show a greater improvement in the angioplasty group. At two years of follow up in one trial, the angioplasty group were more likely to have a patent artery (odds ratio 5.5, 95% confidence interval 1.8 to 17.0) but not a significantly better walking distance or quality of life. In the other trial, long term follow up at six years demonstrated no significant differences in outcome between the angioplasty and control groups. REVIEWER'S CONCLUSIONS: These limited results suggest that angioplasty may have had a short term benefit, but this may not have been sustained.

Angioplasty, Balloon↗
PubMed2000

Doxapram versus methylxanthine for apnea in preterm infants.

BACKGROUND: Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Doxapram and methylxanthine drugs have been used to stimulate breathing and so prevent apnea and its consequences. OBJECTIVES: In preterm infants with recurrent apnea, how does treatment with doxapram compare with treatment with theophylline in leading to a clinically important reduction in apnea and use of mechanical ventilation, without clinically important side effects. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group, as outlined in the Cochrane Library, was used. SELECTION CRITERIA: All trials utilising random or quasi-random patient allocation, in which doxapram was compared with methylxanthine (e.g. theophylline) for the treatment of apnea, were eligible. There must have been an effort to exclude specific causes of apnea. DATA COLLECTION AND ANALYSIS: The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used to select trials, assess quality and to extract and synthesize data. The methodological quality of each trial was reviewed by the second author blinded to trial authors and institution(s). Additional information was requested from authors to clarify methodology. Each author extracted the data separately, then they were compared and differences resolved. Meta-analysis was carried out with use of relative risk and risk difference. MAIN RESULTS: In these trials involving a relatively small number of preterm infants with apnea of prematurity, there is no apparent difference between the effect of intravenous treatment with doxapram or methylxanthine on the incidence of apnea within 48 hours. There were no infants reported to have been given mechanical ventilation on either treatment. No adverse effects were reported. REVIEWER'S CONCLUSIONS: Implications for practice. The overall results of these small trials suggest that intravenous doxapram and intravenous methylxanthine are not different in their effectiveness in the short term in the treatment of apnea of prematurity. Caution is warranted as the number of patients in these trials is too small to exclude an important difference between these two treatments or to exclude the possibility of less common side effects. Longer term outcome of infants treated in these trials has not been reported. Implications for research. Further studies would require a large number of infants, stratified by gestation, to clarify which infants are likely to benefit and whether there might be differences in responses or side effects with these two drugs at different ages. It would be valuable to include important clinical outcomes such as use of mechanical ventilation as well as subsequent growth and development in future studies. Responses to treatment would have to take account of co-interventions, such as nasal continuous airway pressure which is frequently used post-intubation.

Aminophylline↗
PubMed2006

Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults.

BACKGROUND: Internal fixation, commonly used for extracapsular hip fractures, may fail particularly in unstable fractures. Replacement of the hip using arthroplasty, often used for intracapsular fractures, has been used as an alternative. OBJECTIVES: To compare replacement arthroplasty with internal fixation for the treatment of extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for adults with an extracapsular hip fracture. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed 10 aspects of trial quality and extracted data. We requested additional information from trial investigators. Where appropriate, limited pooling of data was performed. MAIN RESULTS: Two randomised controlled trials including a total of 148 people aged 70 years or over with unstable extracapsular hip fractures in the trochanteric region were identified and included in this review. Both had methodological limitations, including inadequate assessment of longer-term outcome. One trial compared a cemented arthroplasty with a sliding hip screw. This found no significant differences between the two methods of treatment for operating time, local wound complications, mechanical complications, reoperation, mortality or loss of independence of previously independent patients at one year. There was, however, a higher blood transfusion need in the arthroplasty group. The other trial compared a cementless arthroplasty versus a proximal femoral nail. It also found a higher blood transfusion need in the arthroplasty group, together with a greater operative blood loss, and a longer length of surgery. There were no significant differences between the two interventions for mechanical complications, local wound complications, reoperation, general complications, mortality at one year or long-term function. None of the pooled outcome data yielded statistically significant differences between the arthroplasty and internal fixation, with the exception of the significantly higher numbers of participants in the arthroplasty group requiring blood transfusion (relative risk 1.71, 95% confidence interval 1.05 to 2.77). AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over internal fixation for extracapsular hip fractures. Further larger well-designed randomised trials comparing arthroplasty versus internal fixation for the treatment of unstable fractures are required.

Fracture Fixation, Internal↗
PubMed2004

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

BACKGROUND: Cephalocondylic intramedullary nails, which are inserted proximally to distally (cephalocondylic), have been used for the surgical treatment of extracapsular hip fractures. OBJECTIVES: To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the fourth substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, several orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: May 2003. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One trial of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. One trial of 230 patients, which compared the Kuntscher-Y nail with the SHS, reported no major difference in outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Two trials, involving 65 patients with reverse and transverse fractures at the level of the lesser trochanter, compared an intramedullary nail (Gamma or PFN nail) with an extramedullary implant (a 90-degree blade plate or dynamic condylar plate). The intramedullary nails were associated with better intra-operative results and fewer fracture fixation complications for these rare fractures. REVIEWER'S CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that the SHS is superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, reversed fracture lines and subtrochanteric fractures).

Adult↗
PubMed2005

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults.

BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants. OBJECTIVES: To compare cephalocondylic intramedullary nails with extramedullary implants (e.g. the sliding hip screw) for extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. MAIN RESULTS: Predominantly older people with mainly trochanteric fractures were treated in the 32 included trials. Twenty trials, involving 3646 people, compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications. Data were inadequate for other outcomes. Five trials, involving 623 people, compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Two trials involving 314 people showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) compared with the SHS. Single trial comparisons (experimental mini-invasive static intramedullary nail compared with the SHS: 60 participants; Kuntscher-Y nail with the SHS: 230 participants; Gamma nail and the Medoff sliding plate: 217 participants) failed to provide sufficient evidence to establish differences between implants in outcome. Two trials, involving 65 people with reverse and transverse fractures at the level of the lesser trochanter, found intramedullary nails (Gamma nail or PFN) were associated with better intra-operative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar plate) for these fractures. AUTHORS' CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, subtrochanteric fractures).

Adult↗
PubMed2000

Glycerol for acute ischaemic stroke.

BACKGROUND: Infarct-related oedema following ischaemic stroke is thought to be a major cause of early death. Intravenous glycerol may reduce the oedema, increase cerebral blood flow and improve cerebral metabolism. OBJECTIVES: The objective of this review was to assess the effect of glycerol in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Medline and Embase. SELECTION CRITERIA: Randomised trials of intravenous glycerol compared with control in people with definite or presumed ischaemic stroke. Trials were included if treatment was initiated within the first four days of stroke onset. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS: Eight trials involving 649 people were included. Based on 454 patients in six trials, glycerol was associated with a decrease in deaths within 14 days of stroke onset (odds ratio of 0.58, 95% confidence interval 0.36 to 0.91). Based on 431 patients in five trials, there was a non-significant decrease in deaths within the first year of stroke onset (odds ratio of 0.82, 95% confidence interval 0.54 to 1.23). The effect of treatment on functional outcome was not clear. Haemolysis appeared to be the only adverse effect. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate glycerol treatment for people with acute ischaemic stroke.

Brain Edema↗
PubMed2000

Pre-operative traction for fractures of the proximal femur.

BACKGROUND: Pre-operative traction following an acute hip fracture remains standard practice in some hospitals. OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE (1983 to August 1999), CINAHL (1982 to July 1999), EMBASE (1980 to September 1999), CENTRAL (Issue 4, 1999 of The Cochrane Library) and bibliographies of trial reports. Date of the most recent search: September 1999. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality, using a nine item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, the data are presented graphically. MAIN RESULTS: Five randomised trials, mainly of moderate quality, involving a total of 635 predominantly elderly patients, were identified and included in the review. The review has been updated twice to include additional and new data from two of the studies. The availability of this additional data resulted in no important change in the results nor conclusions. The four trials which compared traction with no traction found no evidence of benefit from traction, either in the relief of pain, ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other which compared skeletal traction with skin traction found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and most costly. REVIEWER'S CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. Where a policy of general or selective application of traction exists, the choice of method must remain a decision based on evaluation of the individual patient. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

Femoral Fractures↗
PubMed2006

Pre-operative traction for fractures of the proximal femur in adults.

BACKGROUND: Following a hip fracture, traction may be applied to the injured limb before surgery. OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to 2006 Week 11), CINAHL (1982 to March 2006), the UK National Research Register (Issue 1, 2006), conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled. MAIN RESULTS: Ten randomised trials, mainly of moderate quality, involving a total of 1546 predominantly elderly patients with hip fractures, were identified and included in the review. Nine trials compared traction with no traction. Although limited data pooling was possible, overall this provided no evidence of benefit from traction, either in the relief of pain before surgery or ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly. AUTHORS' CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

Adult↗
PubMed2000

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

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

Acne Vulgaris↗
PubMed2000

Cholinergic medication for neuroleptic-induced tardive dyskinesia.

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

Antipsychotic Agents↗
PubMed2000

Conservative interventions for treating distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem particularly in elderly white women with osteoporosis, in whom the lifetime risk of this injury has been estimated as 15 per cent. OBJECTIVES: To determine the most appropriate conservative treatment for fractures (such as Colles') of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline and reference lists of trials. Date of the most recent search: April 1998. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials involving skeletally mature patients with a fracture of the distal radius, which compared commonly applied conservative interventions for fracture fixation. These included the application of an external support (plaster cast or brace) and fracture manipulation. DATA COLLECTION AND ANALYSIS: All trials, judged as fitting the selection criteria by both reviewers, were independently assessed by both reviewers for methodological quality. Data were extracted for anatomical, functional and clinical, including complications, outcomes. The trials were grouped into categories relating to cast position, extent and duration of immobilisation, use of braces, cast material and fracture manipulation. Although quantitative data from some trials are presented, the lack of good quality trials and trial heterogeneity inhibited pooling of results. MAIN RESULTS: Over 50 randomised trials comparing treatment options for distal radial fractures were identified. Twenty nine trials of these, involving a total of 3199 mainly female and older patients, met the inclusion criteria for this review. Comprehensive details of the individual trials are provided in tabular form, and their results, grouped as indicated above, have been presented in text and analyses tables. The poor quality and heterogeneity in terms of patient characteristics, interventions compared and outcome measurement, of the included trials meant that no meta-analyses were undertaken. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Whilst tempting, any call for further research to clarify the most appropriate conservative treatment for this common fracture must be resisted for now. Instead it is important to reflect on the issues raised in this review, to ascertain patient preferences, prioritise researchable questions and undertake a systematic programme of research after agreeing a core data set for classification of fractures and outcomes.

Adult↗
PubMed2006

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults.

BACKGROUND: Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. OBJECTIVES: To compare different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2005), various other databases, conference proceedings and reference lists. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate. MAIN RESULTS: The 14 included trials tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results. Three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates. The two trials comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial comparing the Pugh nail and the SHS found no significant difference between implants. Two trials compared the Medoff plate with the SHS. One trial reported higher blood losses and longer operation times for the Medoff plate. There was a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures. Two trials compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate, but no evidence for differences in longer-term outcomes. Two trials comparing the Gotfried percutaneous plate with a SHS found a reduced blood loss with the Gotfried plate. A higher intra-operative fixation failure rate of the Gotfried plate may indicate some restriction to its use. Two trials found less operative trauma for external fixation when compared with the SHS. Final outcome appeared similar. AUTHORS' CONCLUSIONS: The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable. There was insufficient evidence from other comparisons to draw definite conclusions.

Bone Plates↗
PubMed2000

Long-chain polyunsaturated fatty acid supplementation in preterm infants.

BACKGROUND: This section is under preparation and will be included in the next issue. OBJECTIVES: The n-3 and n-6 essential fatty acids alpha linolenic acid and linoleic acid are the precursors of the n-3 and n-6 longchain polyunsaturated fatty acids (LCPUFA). Controversy exists over whether LCPUFA are essential nutrients for preterm infants who may not be able to synthesise sufficient amounts of LCPUFA to satisfy the needs of the developing brain and retina. The aim of this review is to assess whether supplementation of infant formula with LCPUFA is safe and of benefit to preterm infants. SEARCH STRATEGY: Trials were identified by MEDLINE and by checking reference lists of relevant articles and conference proceedings. SELECTION CRITERIA: All randomised trials of formula supplemented with LCPUFA and with clinical endpoints were reviewed. DATA COLLECTION AND ANALYSIS: Eight randomised trials were identified. Five were assessed as being of high quality and one is awaiting assessment. Problems with the remaining two included a change in assessment methodology mid-study (Memphis 1996) and assessment methodology that deviated from generally accepted international standards (Bologna 1996). MAIN RESULTS: Studies from Dallas (Uauy et al 1990, Birch et al 1992, Hoffman & Uauy 1992, Uauy et al 1994) and Memphis (Carlson et al 1991, Carlson et al 1992, Carlson et al 1993, Werkman & Carlson 1996) suggest that early visual development is better in formula-fed infants who receive a LCPUFA supplement compared with those fed standard formula. However, the effects were not long-term, with no differences detected between groups after 4 months of age. The Bologna group (Fadelli et al 1996) reported some differences in the visual evoked potential at 3 months post-term but their methodology was questionable making interpretation of the data difficult. In the largest study (the Mead Johnson study, Hansen et al 1997), no difference in visual acuity was demonstrated between LCPUFA supplemented and control infants at 2 and 4 months post-term. The Memphis studies used the Fagan Infantest (Fagan 1970) to measure infant development and demonstrated lower novelty preferences (possibly predictive of lower intelligence) in preterm infants supplemented with LCPUFA. However, the supplemented infants had more looks at the novel stimulus and each look was of shorter duration which may represent more rapid visual information processing. Normalised weight (expressed as SD from the mean for age) was lower in preterm infants who were fed supplemented formula in the Memphis studies. No difference in growth between supplemented and control infants was documented in the Dallas, Bologna, Alberta (Clandinin et al 1997) and Wyeth (Vanderhoof et al 1997) studies while the Mead Johnson study documented higher weights in supplemented infants compared with controls at two months post-term. The Dallas study documented little effect of LCPUFA supplements on bleeding time and membrane fragility. REVIEWER'S CONCLUSIONS: No long-term benefit has been demonstrated for preterm infants receiving formula supplemented with LCPUFA. There is some evidence that n-3 LCPUFA supplementation of formula increases the early rate of visual maturation in preterm infants. Supplementation of formula with n-3 and n-6 LCPUFA does not impair the growth of preterm infants.

Dietary Supplements↗
PubMed2004

Longchain polyunsaturated fatty acid supplementation in preterm infants.

BACKGROUND: The n-3 and n-6 essential fatty acids alpha linolenic acid (ALA) and linoleic acid (LA) are the precursors of the n-3 and n-6 longchain polyunsaturated fatty acids (LCPUFA). Controversy exists over whether LCPUFA are essential nutrients for preterm infants who may not be able to synthesise sufficient amounts of LCPUFA to satisfy the needs of the developing brain and retina. OBJECTIVES: The aim of this review is to assess whether supplementation of formula with LCPUFA is safe and of benefit to preterm infants. SEARCH STRATEGY: Trials were identified by MEDLINE (October 2003), Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003) and by checking reference lists of relevant articles and conference proceedings. SELECTION CRITERIA: All randomised trials of formula supplemented with LCPUFA and with clinical endpoints were reviewed. DATA COLLECTION AND ANALYSIS: Eleven randomised trials assessing the clinical effects of feeding formula supplemented with LCPUFA were included in the review. MAIN RESULTS: Of the eleven randomised trials included in the review, two of these were not classified as of high quality despite blinded assessment and complete follow-up, due to problems with assessment methodology. VISUAL ACUITY: Visual acuity over the first year was measured by Teller acuity cards in six studies, by VEP in four studies and by ERG in two studies. Most studies found no significant differences in any visual assessment between supplemented and control infants. DEVELOPMENT: Most of the trials have used Bayley Scales of Infant Development (BSID) at 12 to 24 months postterm and shown no significant effect following supplementation. Meta-analysis of BSID of three studies (Fewtrell 2002, O'Connor 2001, van Wezel 2002) shows no significant effect of supplementation on development. Carlson 1993 and Carlson 1996 demonstrated lower novelty preferences (possibly predictive of lower intelligence) in the supplemented compared with the control group. The investigators however concluded that supplemented infants may have more rapid visual information processing given that they had more looks and each look was of shorter duration. GROWTH: Most trials have reported no significant effect of LCPUFA supplementation on growth of preterm infants. Two trials (Carlson 1993, Carlson 1996) suggest that LCPUFA supplemented infants grow less well than controls, possibly due to a reduction in AA levels which occurs when n-3 supplements are used without n-6 supplements. Recent trials with addition of AA to the supplement have reported no significant effect on growth. Fewtrell 2002 reported mild reductions in length and weight z scores at 18 months. Contrary to these results, the meta-analysis of five studies (Uauy 1992, Carlson 1996, Hansen 1997, Vanderhoof 1999, Innis 2002) showed increased weight and length at two months post-term in supplemented infants. SIDE EFFECTS: Uauy 1992 reported no significant effect of LCPUFA supplementation on bleeding time and red cell membrane fragility. REVIEWER'S CONCLUSIONS: Infants enrolled in the trials were relatively mature and healthy preterm infants. Assessment schedule and methodology, dose and source of supplementation and fatty acid composition of the control formula varied between trials. No long-term benefits were demonstrated for infants receiving formula supplemented with LCPUFA. There was no evidence that supplementation of formula with n-3 and n-6 LCPUFA impaired the growth of preterm infants.

Dietary Supplements↗
PubMed2000

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment.

BACKGROUND: Delirium is common in hospitalized elderly people. In the frail elderly, delirium may occur in 60% of those hospitalized. In the cognitively impaired, 45% have been shown to develop delirium and these patients have longer lengths of stay and a higher rate of complications which, amongst other things, together contribute to an increase in cost of care. The combination of being elderly and chronically cognitively impaired leads to a high risk of delirium with the associated increased risk of prolonged hospital stay, complications, and poor outcomes. The management of delirium has commonly been multifaceted - the primary emphasis has always been on the diagnosis and therapy of the precipitating factors, but as this may not be immediately resolved, symptomatic and supportive care may become of major importance. OBJECTIVES: The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of patients with delirium superimposed on an underlying chronic cognitive impairment compared with the usual care of older cognitively impaired patients. SEARCH STRATEGY: The Cochrane Controlled Trials Register (Cochrane Library, up to and including Issue 1, 1998) was searched using the terms 'delirium, controlled trial, cognitive'. MEDLINE, EMBASE and Psychlit (Ovid via Winspirs up to Feb 1998) were also searched with the same terms. Other sources including personal communications, ongoing trials, conference proceedings, handsearching and reference lists of published papers and books were all searched for relevant randomized controlled trials. The total yield from searching was 157 from which 8 (eight) were retained for consideration in the review. SELECTION CRITERIA: From the initial search yields, all randomised controlled trials involving the management of elderly patients with delirium were identified. A single reviewer (AMB) discarded irrelevant publications based on the title of the publication and its abstract. In the event that the article could possibly be relevant, it was retrieved for further assessment. All references were compiled in a list with a commentary on type of article, eg review, prospective study etc and this was independently considered by the second reviewer (RR) who agreed to review all randomised controlled studies reported on patients with delirium. Selection for possible inclusion in this review was then made on the basis of the participants reported as having chronic cognitive impairment, who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. The outcomes of interest were length of stay in hospital, morbidity (including complications), patient distress & impact on care environment, mortality, discharge arrangements and follow-up including assessment of cognitive function at 6 months. Studies in which patients with chronic cognitive impairment or dementia, managed for incident delirium, according to ICD 9 criteria (see note) were considered eligible for inclusion in the review. Studies of risk factors and non-randomized studies were excluded. Note: this classification has been widely utilised throughout the English speaking medical literature over the past 20 years: ICD 10 is still being incorporated into clinical coding systems and has not been utilised in studies published in 1996. (ABSTRACT TRUNCATED)

Delirium↗
PubMed2000

Oral calorie supplements for cystic fibrosis.

BACKGROUND: Poor nutrition occurs frequently in children and adults with cystic fibrosis and is associated with a number of other adverse outcomes. Oral calorie supplements are used to try and increase total daily calorie intake and improve weight gain. However, they are expensive and there are concerns that they may lead to a reduction in the amount of food eaten and no overall improvement in energy intake. OBJECTIVES: To examine the evidence that in patients with cystic fibrosis, oral calorie supplements increase daily calorie intake, improve overall nutritional intake, nutritional indices, lung function, survival and quality of life. To assess possible adverse effects associated with use of oral calorie supplements. SEARCH STRATEGY: The Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. The companies which market oral calorie supplements were also contacted. Date of the most recent search of the Group's specialised register: November 1999. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing use of oral calorie supplements for at least one month to increase calorie intake with no specific intervention or additional nutritional advice in patients with cystic fibrosis. DATA COLLECTION AND ANALYSIS: The following outcomes were assessed: indices of nutrition and growth, anthropometric measures of body composition, calorie intake (total, from oral calorie supplements and from food), nutrient intake, eating behaviour, quality of life, specific adverse effects, lung function and mortality. MAIN RESULTS: Two trials which reported results from a total of 29 patients were suitable for inclusion in the review. From the data provided in the published reports only one item (change in weight) could be extracted from one trial for inclusion in the review. This showed no difference between intervention and comparison group. REVIEWER'S CONCLUSIONS: Oral calorie supplements are very widely used around the world in an attempt to improve nutritional status in patients with cystic fibrosis, at some considerable cost. It is therefore very disappointing that their effectiveness has not been assessed by adequate clinical trials. No conclusions can be made about the use of oral calorie supplements in cystic fibrosis from the information currently available and clinicians must balance potential benefits against possible adverse effects of treatment in making decisions about individual patients. This systematic review has clearly identified the need for a well designed, adequately-powered, multicentre, randomised controlled trial assessing the effectiveness and possible adverse effects of oral calorie supplements in cystic fibrosis.

Adult↗
PubMed2000

Therapeutic ultrasound for postpartum perineal pain and dyspareunia.

BACKGROUND: Proponents of therapeutic ultrasound suggest it can decrease pain by resolution of inflammation processes and reducing the pressure on pain sensitive structures by haematoma and oedema. OBJECTIVES: The objective of this review was to assess the effects of therapeutic ultrasound for treating acute perineal pain, persistent perineal pain and/or dyspareunia, following childbirth. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register, Embase, Cinahl (to May 1996), Physiotherapy Index (1985 to May 1996) and World Congress of Physical Therapy 1994 Conference Proceedings. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing active therapeutic ultrasound with no treatment, placebo ultrasound, or any other 'standard' or active treatment for women with acute or persistent perineal pain and/or dyspareunia following childbirth. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality and extracted data. MAIN RESULTS: Four trials involving 659 women were included. The trials were of variable quality. Based on two placebo controlled trials, women treated with active ultrasound for acute perineal pain were more likely to report improvement in pain with treatment (odds ratio 0.37, 95% confidence interval 0.19 to 0.69). No other outcome reached significance. In one trial comparing pulsed electromagnetic energy with ultrasound for acute perineal pain, women treated with ultrasound were more likely to have bruising at 10 days (odds ratio 1.64, 95% confidence interval 1.04 to 2.60). However those treated with ultrasound were less likely to have experienced perineal pain at 10 days (odds ratio 0.56, 95% confidence interval 0.34 to 0.92) and three months (odds ratio 0.43, 95% confidence interval 0.22 to 0.84). No other outcome reached significance. Based on one trial, women treated with ultrasound for persistent perineal pain and/or dyspareunia were less likely to report pain with sexual intercourse compared with the placebo group (odds ratio 0.31, 95% confidence interval 0.11 to 0.84). None of the other outcomes measured reached significance. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of ultrasound in treating perineal pain and/or dyspareunia following childbirth.

Dyspareunia↗