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PubMed2006

Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review.

OBJECTIVE: To assess the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations. DATA SOURCES: Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), and MEDLINE. The search terms "fractures," "manipulation, orthopedic," "an(a)esthetics," "analgesics," and "hypnotics and sedatives" were used. STUDY SELECTION: Studies were included if they were randomized controlled trials studying sedative and/or analgesic regimens for fracture reductions in pediatric patients in the emergency department. The search yielded 915 references. From these, 8 studies including 1086 patients were selected. DATA EXTRACTION: Interventions studied included intravenous regional blocks (Bier blocks), nitrous oxide, and parenteral combinations. Data on measures of effectiveness and safety were extracted. DATA SYNTHESIS: Ketamine hydrochloride-midazolam hydrochloride was associated with less distress during reduction than fentanyl citrate-midazolam or propofol-fentanyl. Patients receiving ketamine-midazolam required significantly fewer airway interventions than those in whom either fentanyl-midazolam or propofol-fentanyl were used. Data comparing Bier blocks with systemic forms of sedation or analgesia were limited. CONCLUSIONS: Ketamine-midazolam seems to be more effective and have fewer adverse events than fentanyl-midazolam or propofol-fentanyl. Data on other forms of analgesia or sedation are too limited to make comparisons. More research is needed to define the regimen that maximizes safety, efficacy, and efficiency for fracture reduction in pediatric patients.

Analgesics↗
PubMed1997

Low birth weight and Latino ethnicity. Examining the epidemiologic paradox.

OBJECTIVE: To assess the relation between Latino ethnicity, Latino subgroup, and low birth weight (LBW). DATA SOURCES: From the MEDLINE computer data-base, we used the key words birth weight; infant, LBW; Latinos; Hispanic Americans; Cuban Americans; Mexican Americans; and Puerto Ricans to identify studies that analyzed LBW in Latinos. STUDY SELECTION: Thirty-two studies, published from 1982 to 1996, that analyzed US Latinos and whites or multiple Latino subgroups, that used the revised definition of LBW (< 2500 g), and had a large sample size (> 10,000) were selected. DATA EXTRACTION: Two reviewers extracted LBW rates and data on the relation between Institute of Medicine risk factors and LBW by maternal ethnicity and Latino subgroup. DATA SYNTHESIS: Low-birth-weight rates were similar for Latino (median, 6.2%) and white infants (median, 5.8%). By Latino subgroup, LBW rates were similar for Central/South American, Cuban, Mexican, and white infants. Puerto Rican infants had consistently higher LBW rates (median, 9.1%). Two risk factors-maternal birth-place and gestational weight gain-were identified as confounders of the relation between Latino ethnicity, Latino subgroup, and LBW. CONCLUSIONS: Low-birth-weight rates of Latinos and whites are similar, consistent with the "epidemiologic paradox" of unexpectedly favorable perinatal outcomes for Latinos. However, this paradoxical relation for all Latinos masks the notably elevated LBW risk among Puerto Ricans. Further study of LBW among Latinos, including cultural factors, is needed.

Confounding Factors, Epidemiologic↗
PubMed1997

Metered-dose inhaler accessory devices in acute asthma: efficacy and comparison with nebulizers: a literature review.

OBJECTIVES: To evaluate the current literature about the efficacy of providing inhaled medications by metered-dose inhalers and accessory devices (MDI/ADs) to children with acute asthma and to compare it with the current standard of care, small-volume nebulizers (SVNs). DATA SOURCES: Online computer and manual searches in English-language journal articles published between 1980 and 1996. STUDY SELECTION: Seventeen prospective clinical trials that have used MDI/ADs in the treatment of acute asthma in children were retrieved. Ten randomized controlled studies that included a comparison with SVN treatment were selected. DATA EXTRACTION: Studies were assessed qualitatively by their subject characteristics, design, intervention procedures, outcome measures, and results. DATA SYNTHESIS: There were marked variations in types of MDI/ADs and in doses administered between and within studies. Major outcome measures included pulmonary function measurements and clinical scores. All studies found MDI/ADs to be effective in the treatment of infants and children with acute asthma. Among those who compared this treatment with SVN, 2 found the MDI/AD superior and the rest found it as effective as the SVN. CONCLUSIONS: The data support the effectiveness of MDI/ADs as first-line treatment in acute childhood asthma. In view of clinical benefit, safety, lower cost, personnel time, and speed and ease of administration of MDI/ADs compared with SVNs, MDI/ADs should be considered the preferred mode of treatment of children with acute asthma.

Acute Disease↗
PubMed2005

The surgeon and AIDS: twenty years later.

BACKGROUND: Since the first reports on indications and outcome for abdominal procedures in the HIV/AIDS patient were published 20 years ago, the epidemiology and presentation of surgical illness have changed remarkably with the advent of new antiviral regimens. A review of the now occasional, but still important, role of the surgeon in contemporary treatment of HIV/AIDS is presented. DATA SOURCES: Information was obtained by PubMed searches of medical journals, examination of reference lists, and Web resources. STUDY SELECTION: Articles on operative indications, outcomes, precautions, source of transmission, and pathophysiology of HIV/AIDS were selected. DATA EXTRACTION: Data was obtained from peer-reviewed articles and references. DATA SYNTHESIS: The last 2 decades have seen a decrease in operative mortality from as high as 85% to approximately 15% with a corresponding improvement in morbidity. Surgical emergencies such as appendicitis occur in HIV patients with the same frequency as non-HIV patients and are treated with equivalent results. Concern about transmission of HIV in the operating room has lessened somewhat. Although still a hazard, the probability of HIV transmission with accidental exposure is low, with risks below 0.5% for percutaneous hollow-bore needles and less than 0.1% risk for mucus membrane exposure. CONCLUSIONS: Improved surgical outcomes together with of accurate data on the modes and likelihood of accidental transmission of HIV to members of the surgery team have resulted in the treatment of HIV/AIDS patients becoming an accepted part of routine surgical practice.

Abdomen, Acute↗
PubMed2002

Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis.

CONTEXT: The cognitive and behavioral outcomes of school-aged children who were born preterm have been reported extensively. Many of these studies have methodological flaws that preclude an accurate estimate of the long-term outcomes of prematurity. OBJECTIVE: To estimate the effect of preterm birth on cognition and behavior in school-aged children. DATA SOURCES: MEDLINE search (1980 to November 2001) for English-language articles, supplemented by a manual search of personal files maintained by 2 of the authors. STUDY SELECTION: We included case-control studies reporting cognitive and/or behavioral data of children who were born preterm and who were evaluated after their fifth birthday if the attrition rate was less than 30%. From the 227 reviewed studies, cognitive data from 15 studies and behavioral data from 16 studies were selected. DATA EXTRACTION: Data on population demographics, study characteristics, and cognitive and behavioral outcomes were extracted from each study, entered in a customized database, and reviewed twice to minimize error. Differences between the mean cognitive scores of cases and controls were pooled. Homogeneity across studies was formally tested using a general variance-based method and graphically using Galbraith plots. Linear meta-analysis regression models were fitted to explore the impact of birth weight and gestational age on cognitive outcomes. Study-specific relative risks (RRs) were calculated for the incidence of attention-deficit/hyperactivity disorder (ADHD) and pooled. Quality assessment of the studies was performed based on a 10-point scale. Publication bias was examined using Begg modified funnel plots and formally tested using the Egger weighted-linear regression method. DATA SYNTHESIS: Among 1556 cases and 1720 controls, controls had significantly higher cognitive scores compared with children who were born preterm (weighted mean difference, 10.9; 95% confidence interval [CI], 9.2-12.5). The mean cognitive scores of preterm-born cases and term-born controls were directly proportional to their birth weight (R(2) = 0.51; P<.001) and gestational age (R(2) = 0.49; P<.001). Age at evaluation had no significant correlation with mean difference in cognitive scores (R(2) = 0.12; P =.20). Preterm-born children showed increases in externalizing and internalizing behaviors in 81% of studies and had more than twice the RR for developing ADHD (pooled RR, 2.64; 95% CI, 1.85-3.78). No differences were noted in cognition and behaviors based on the quality of the study. CONCLUSIONS: Children who were born preterm are at risk for reduced cognitive test scores and their immaturity at birth is directly proportional to the mean cognitive scores at school age. Preterm-born children also show an increased incidence of ADHD and other behaviors.

Attention Deficit Disorder with Hyperactivity↗
PubMed2000

Ancient DNA analysis of human populations.

The use of ancient DNA (aDNA) in the reconstruction of population origins and evolution is becoming increasingly common. The resultant increase in number of samples and polymorphic sites assayed and the number of studies published may give the impression that all technological hurdles associated with aDNA technology have been overcome. However, analysis of aDNA is still plagued by two issues that emerged at the advent of aDNA technology, namely the inability to amplify a significant number of samples and the contamination of samples with modern DNA. Herein, we analyze five well-preserved skeletal specimens from the western United States dating from 800-1600 A.D. These specimens yielded DNA samples with levels of contamination ranging from 0-100%, as determined by the presence or absence of New World-specific mitochondrial markers. All samples were analyzed by a variety of protocols intended to assay genetic variability and detect contamination, including amplification of variously sized DNA targets, direct DNA sequence analysis of amplification products and sequence analysis of cloned amplification products, analysis of restriction fragment length polymorphisms, quantitation of target DNA, amino acid racemization, and amino acid quantitation. Only the determination of DNA sequence from a cloned amplification product clearly revealed the presence of both ancient DNA and contaminating DNA in the same extract. Our results demonstrate that the analysis of aDNA is still an excruciatingly slow and meticulous process. All experiments, including stringent quality and contamination controls, must be performed in an environment as free as possible of potential sources of contaminating DNA, including modern DNA extracts. Careful selection of polymorphic markers capable of discriminating between ancient DNA and probable DNA contaminants is critical. Research strategies must be designed with a goal of identifying all DNA contaminants in order to differentiate convincingly between contamination and endogenous DNA.

Animals↗
PubMed1999

Capillary electrophoresis-diode array detection--electrospray mass spectrometry for the analysis of selected tropane alkaloids in plant extracts.

Capillary zone electrophoresis, coupled to UV and interfaced with electrospray ionization mass spectrometry (ESI-MS), is described for the simultaneous analysis of hyoscyamine and scopolamine. On-line UV detection occurred at 22 cm from the inlet of the capillary and ESI-MS monitoring was performed along the entire length of the capillary (85 cm). An alkaline solution of 40 mM ammonium acetate at pH 8.5 was suitable for the analysis of the alkaloids under consideration. Under the optimized conditions, including CE and ESI-MS parameters, the two alkaloids were resolved within a short time and with very high sensitivity. The differentiation of hyoscyamine and its positional isomer littorine, commonly encountered in plant material, is also presented using up-front collision-induced dissociation. Finally, the developed method was applied to the analysis of these alkaloids in Belladonna leaf extract and in Datura candida x D. aurea hairy root extract.

Alkaloids↗
PubMed1990

Mitogenic effect of neurotrophic factors on human IMR 32 neuroblastoma cells.

The effect of growth factors with neurotrophic properties on proliferation of the human IMR 32 neuroblastoma (NB) cell line was studied. A colorimetric proliferation assay and an anchorage-dependent cell culture system were used. Basic fibroblast growth factor (bFGF), nerve growth factor (NGF), neurite-inducing factor (NIF), ciliary neurotrophic factor (CNTF), and a cell-free extract from selected embryonic chick eye tissues (CIPE) were assayed for their capacity to control proliferation. Basic FGF, NGF, and CIPE stimulated proliferation of IMR 32 NB cells in serum-containing culture conditions. The NIF and CNTF had no effect. The concentration of bFGF required to induce half-maximal cell growth was 4.6 +/- 1.8 ng/ml, but the half-maximally effective dose of NGF was 7.5 +/- 2.7 ng/ml. In combination these two growth factors were additive within a small concentration range. In serum-free culture conditions bFGF affected both proliferation and cell differentiation by promoting neurite growth and cell aggregate formation. In contrast, NGF induced cell neurite outgrowth only. These results, in conjunction with the evidence that bFGF-like molecules are present, in IMR 32 NB cells may support the notion that NB cells regulate their proliferation by an autocrine mechanism. Basic FGF and NGF, two distinct neurotrophic factors, appear to be involved in the regulation of NB cell proliferation.

Cell Division↗
PubMed2003

Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery.

BACKGROUND: Peripheral arterial disease (PAD) may cause occlusions (blockages) in the main arteries of the lower limbs. It is frequently treated by implantation of either an infrainguinal autologous (using the patient's own tissue) venous or artificial graft. A number of factors influence occlusion rates, including the material used. To prevent graft occlusion, patients are usually treated with either an antiplatelet or antithrombotic drug, or a combination of both. OBJECTIVES: To evaluate whether antiplatelet treatment in patients with symptomatic PAD undergoing infrainguinal bypass surgery improves graft patency, limb salvage and survival. SEARCH STRATEGY: The reviewers searched the Cochrane Peripheral Vascular Diseases Group Specialised Register, (last searched April 2003), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 1, 2003). Additional trials were sought through reference lists of papers and by reviewing proceedings from the vascular surgical society meetings. SELECTION CRITERIA: The methodological quality of each trial was assessed independently by two reviewers (JD, MMK), with emphasis on concealment of randomisation. DATA COLLECTION AND ANALYSIS: Details of the studies selected were extracted independently by two reviewers (JD, MMK), and an 'intention-to-treat' analysis performed. The treatment and control groups were compared for important prognostic factors and differences described. If any data were not available, further information was sought from the author. Data were synthesized by comparing group results. MAIN RESULTS: The administration of a variety of platelet-inhibitors resulted in improved venous and artificial graft patency compared to no treatment. However, analysing patients for graft-type indicated that patients receiving a prosthetic graft were more likely to profit from administration of platelet-inhibitors than those treated with a venous graft. REVIEWER'S CONCLUSIONS: Antiplatelet therapy with aspirin had a slight beneficial effect on the patency of peripheral bypasses, but seemed to have an inferior effect on venous graft patency compared with artificial grafts. The effect of aspirin on cardiovascular outcomes and survival was mild and not statistically significant; this might be due to the fact that the majority of patients receiving a peripheral graft have an advanced stage of PAD with critical ischemia. These patients are usually seriously ill with respect to cardiovascular diseases with high mortality rates of 20% per year. Additionally, the number of patients included in this analysis might still be too small to reach a statistically significant effect for mortality and cardiovascular morbidity.

Arteriosclerosis↗
PubMed2002

Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain.

BACKGROUND: Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies. OBJECTIVES: To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain. SEARCH STRATEGY: We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. INTERVENTION specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration. SELECTION CRITERIA DESIGN: randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention. POPULATION: Adults with disabling low back pain of more than three months in duration. INTERVENTION: Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions. OUTCOMES: Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement. Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded. DATA COLLECTION AND ANALYSIS: Selection, data extraction and quality grading of studies was done by two independent reviewers using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between reviewers were resolved by consensus or by a third reviewer. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent. MAIN RESULTS: Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments. REVIEWER'S CONCLUSIONS: The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.

Back Pain↗
PubMed2005

Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults.

BACKGROUND: Anterior cruciate ligament rupture is a common knee injury. Surgical treatment, usually involving reconstruction of the ligament, is widely used especially in active individuals. OBJECTIVES: Evaluation of the effect of surgical treatment compared with conservative treatment of anterior cruciate ligament (ACL) rupture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to January Week 3 2005), EMBASE (1988 to 2005 Week 05), MEDIC (1978 to January 1999), Current Contents (9.2.1998 to 1.2.1999), BIOSIS (1970 to December 1998), reference lists of articles and consulted trialists and experts. SELECTION CRITERIA: All randomised and quasi-randomised trials that compared surgical with conservative treatment of ACL rupture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction and quality assessment. MAIN RESULTS: Two poor quality randomised trials conducted in the early 1980s were included in the review. The two trials differed considerably and no data pooling was done for the few shared outcome measures. One quasi-randomised trial of 167 people with a complete ACL rupture treated with repair or augmented repair versus conservative treatment found no difference in the return to sports activities between people treated surgically and those treated conservatively. Measures of knee stability and functional (Lysholm) knee scores were higher in surgically-treated participants. By the end of the follow-up period (average 55 months), three people treated with repair only and 16 treated conservatively had had ACL reconstruction. The other trial included 157 people with ACL injury. This found that conservatively-treated participants recovered from their injury more rapidly but, at the last follow up (minimum 13 months), the functional outcome was similar in both treatment groups. A large proportion of participants experienced some temporary discomfort after surgery and there were some more serious postoperative complications. There was less knee instability in surgically-treated participants and a tendency to fewer subsequent operations in the longer term. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice. Good quality randomised trials are required to remedy this situation.

Adult↗
PubMed2005

Nutritional supplementation for hip fracture aftercare in older people.

BACKGROUND: Fractures of the hip are an important cause of later ill health and mortality in older people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. OBJECTIVES: This review assesses the effects of nutritional interventions in older people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2004), MEDLINE (1966 to October week 1 2004), Nutrition Abstracts and Reviews, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, the National Research Register and reference lists. We contacted investigators and handsearched four nutrition journals. SELECTION CRITERIA: Randomised and quasi-randomised trials of nutritional interventions for mainly older people (aged over 65 years) with hip fracture. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from all trialists, and pooled data for primary outcomes. MAIN RESULTS: Eighteen randomised trials involving 1306 participants were included. Overall trial quality was poor; specifically in terms of allocation concealment, assessor blinding and intention-to-treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Eight trials evaluated oral multinutrient feeds: these provided non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97), but the studies were heterogeneous regarding case mix. There was insufficient information for other outcomes. The specific effect of protein given in an oral feed was tested in three trials. There was no evidence for an effect on mortality (RR 1.38, 95% CI 0.82 to 2.34). Protein supplementation may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either vitamin supplement. AUTHORS' CONCLUSIONS: While some evidence exists for the effectiveness of oral protein and energy feeds, overall the evidence for the effectiveness of nutritional supplementation remains weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Aftercare↗
PubMed2006

Nutritional supplementation for hip fracture aftercare in older people.

BACKGROUND: Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently. OBJECTIVES: To review the effects of nutritional interventions in older people recovering from hip fracture. 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 2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes. MAIN RESULTS: Twenty-one randomised trials involving 1727 participants were included. Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention-to-treat analysis, and limited availability of outcome data. Eight trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes. Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications. Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement. One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11). AUTHORS' CONCLUSIONS: Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. Adequately sized trials are required which overcome the methodological defects of the reviewed studies. In particular, the role of dietetic assistants requires further evaluation.

Aftercare↗
PubMed2006

Intravenous immunoglobulin for Guillain-Barré syndrome.

BACKGROUND: Guillain-Barré syndrome is an acute, paralysing, inflammatory peripheral nerve disease. Intravenous immunoglobulin is beneficial in other autoimmune diseases. OBJECTIVES: We aimed to determine the efficacy of intravenous immunoglobulin for treating Guillain-Barré syndrome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (March 2005), MEDLINE (January 1966 to March 2005) and EMBASE (January 1980 to March 2005) using the terms 'Guillain-Barré syndrome' and 'acute polyradiculoneuritis'. SELECTION CRITERIA: We included all randomised and quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Two authors independently selected papers, extracted data and assessed quality. MAIN RESULTS: Another Cochrane systematic review has shown that plasma exchange significantly hastens recovery. We found six randomised trials comparing intravenous immunoglobulin with plasma exchange. We undertook a meta-analysis of five trials involving 536, mostly adult participants who were unable to walk unaided and had been ill for less than two weeks. Our primary outcome measure was the change in a seven-grade disability scale four weeks after randomisation. The weighted mean difference of this measure was not statistically significant, being only -0.02 (95% confidence interval -0.25 to 0.20) of a disability grade more improvement in the intravenous immunoglobulin than the plasma exchange group. There were no statistically significant differences in other measures. One trial involving 249 participants compared plasma exchange followed by intravenous immunoglobulin with plasma exchange alone. Another involving 37 participants compared immunoabsorption followed by intravenous immunoglobulin with immunoabsorption alone. Neither revealed significant extra benefit from intravenous immunoglobulin. One study with 39 participants showed a trend towards more improvement with high-dose compared with low-dose intravenous immunoglobulin. Another trial with 51 children found no significant difference in outcome when the standard dose was given over two days rather than five days. Three studies including a total of 75 participants suggested that in children intravenous immunoglobulin significantly hastens recovery compared with supportive care. AUTHORS' CONCLUSIONS: In adults, there are no adequate comparisons with placebo. Randomised trials in severe disease show that intravenous immunoglobulin started within two weeks from onset hastens recovery as much as plasma exchange, which is known to be more effective than supportive care. Treatment with intravenous immunoglobulin is significantly more likely to be completed than plasma exchange. Giving intravenous immunoglobulin after plasma exchange did not confer significant extra benefit. In children, intravenous immunoglobulin probably hastens recovery compared with supportive care alone. More research is needed in mild disease and in treatment starting more than two weeks after onset of the condition. Dose-ranging studies are also needed.

Child↗
PubMed2001

Prompts to encourage appointment attendance for people with serious mental illness.

BACKGROUND: Prompts to encourage attendance at clinics are often used in day-to-day practice by diligent carers of people with mental health problems. These may take the form of telephone prompting, financial incentives or issuing a copy of the referral letter to the appointee. OBJECTIVES: To estimate the effects of simple prompting by professional carers to encourage attendance at clinics for those with serious mental illness. SEARCH STRATEGY: Methodical searches of Biological Abstracts (1985-2000), CINAHL (1982-2000), Cochrane Schizophrenia Group's Register (June 2000), Cochrane Library (Issue 2, 2000), EMBASE (1980-2000), MEDLINE (1966-2000) and PsycLIT (1887-2000) were undertaken. These were supplemented by searching of reference lists, personal contact and hand searching of high yield journals. SELECTION CRITERIA: All relevant randomised (or quasi-randomised) studies comparing the addition of 'prompts' to standard care for those with serious mental illnesses such as schizophrenia. Prompts had the stated purpose of encouraging attendance or contact with mental health teams and could be text-based, electronic, by telephone call, by personal visit, or could employ financial or other rewards. DATA COLLECTION AND ANALYSIS: Studies and data were independently selected and extracted. For homogeneous dichotomous data the random effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data the reviewers calculated weighted mean differences. MAIN RESULTS: Only three relevant trials were identified (total n=597). It is not clear whether there is any real difference between attendance of those prompted by telephone one or two days before the appointment, and those given the standard appointment management system (2 trials, n=457, RR missed appointment 0.84 CI 0.7 to 1.1). Text-based prompts, a few days before the appointment day, did increase clinic attendance when compared with no prompt (2 trials, n=200, RR missed appointment 0.6 CI 0.4 to 0.9, NNT 6 CI 2 to 14). Only one small study (n=61) reported data on the combination of telephone and text-based prompts versus no prompt (RR missed appointments 0.7 CI 0.4 to 1.2). When telephone prompts were compared with text-based prompts (1 trial, n=75), the latter, in the form of an 'orientation statement' (a short paragraph, taking about 30 seconds to read, explaining the programme of care, the fee system, and providing gentle encouragement) may be somewhat more effective than the telephone prompt (RR missed appointments 1.9 CI 0.98 to 3.8). One last study (n=120) compared a standard letter prompt with a letter 'orientation statement'. Overall, results tended to favour the orientation statement approach rather than the simple letter prompting attendance but the results did not reach conventional levels of statistical significance (RR missed appointments 1.6 CI 0.9 to 2.9). REVIEWER'S CONCLUSIONS: There is evidence that a simple prompt to attend clinic, very close to the time of the appointment may encourage attendance, and a simple orientation-type letter, 24 hours before the clinic appointment, may be more effective than a telephone prompt. This simple intervention could be a more cost effective means of encouraging compliance at first attendance, but supplementing these data with the results of large, well designed, conducted and reported randomised studies would be desirable.

Appointments and Schedules↗
PubMed2005

Treadmill training and body weight support for walking after stroke.

BACKGROUND: Treadmill training, with or without some body weight supported using a harness, is a method of treating walking after stroke. A systematic review is required to assess the cost, effectiveness, and acceptability of this treatment. OBJECTIVES: To assess the effectiveness of treadmill training and body weight support, individually or in combination, in the treatment of walking after stroke. The primary outcomes investigated were walking speed, endurance and dependency. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched 2 March 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1980 to February 2005), CINAHL (1982 to February 2005) and PEDro (last searched 2 March 2005). In addition, we handsearched relevant conference proceedings, screened reference lists and contacted trialists to identify further published and unpublished trials. SELECTION CRITERIA: Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke were eligible. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, extracted data, and assessed quality. We contacted trialists for additional information. We used a fixed-effect model for analysis, but if heterogeneity existed a random-effects model was used. We analysed the results as weighted mean differences (WMD) for continuous variables and relative risk (RR) for dichotomous variables. MAIN RESULTS: Fifteen trials (622 participants) were included. There were no statistically significant differences between treadmill training, with or without body weight support, and other interventions for walking speed or dependence. Among participants who could walk independently at the start of treatment, treadmill training with body weight support tended to produce higher walking speeds (WMD 0.09 m/s, 95% confidence interval (CI) -0.02 to 0.20 for speed; fixed-effect), but this result was not statistically significant. An individual trial tended to support the use of treadmill training with body weight support for dependent walkers as compared to treadmill training alone. One of three individual trials indicated that independent walkers may benefit from treadmill training combined with other task-orientated exercise. However, data are very limited. Adverse events occurred more frequently in participants receiving treadmill training but these were not judged to be clinically serious events. AUTHORS' CONCLUSIONS: Overall no statistically significant effect of treadmill training with or without body weight support was detected. Although individual studies suggested that treadmill training with body weight support may be more effective than treadmill training alone and that treadmill training plus task-oriented exercise may be more effective than sham exercises, further trials are required to confirm these findings.

Body Weight↗
PubMed2005

School-based prevention for illicit drugs' use.

BACKGROUND: Drug addiction is a chronic, relapsing disease. Primary interventions should be aimed to reduce first use, or prevent the transition from experimental use to addiction. School is the appropriate setting for preventive interventions. OBJECTIVES: To evaluate the effectiveness of school-based interventions in improving knowledge, developing skills, promoting change, and preventing or reducing drug use versus usual curricular activities or a different school-based intervention . SEARCH STRATEGY: MEDLINE , EMBASE, ERIC, PSYCHINFO, Cochrane Library, ACP Journal Club, Cochrane Drug and Alcohol Group Register, updated to February 2004, were searched. Bibliography of papers was checked and personal contacts were made to identify other relevant studies. SELECTION CRITERIA: RCTs, CCTs or Controlled Prospective Studies (CPS) evaluating school-based interventions designed to prevent substance use. DATA COLLECTION AND ANALYSIS: Data were selected and extracted independently by two reviewers. Quality was assessed with the CDAG checklist. Interventions were classified as skills, affective, knowledge-focused and other characteristics were also studied (teaching, follow-up implementation, context activation). MAIN RESULTS: 32 studies (29 RCTs and 3 CPSs) were included. 28 were conducted in the USA; most were focused on 6th-7th grade students, and based on post-test assessment. RCTs: (1) Knowledge vs usual curricula: Knowledge focused programs improve drug knowledge (SMD=0.91; 95% CI: 0.42, 1.39).(2) Skills vs usual curricula: Skills based interventions increase drug knowledge (WMD=2.60; 95% CI: 1.17-4.03), decision making skills (SMD=0.78; CI95%: 0.46-1.09), self-esteem (SMD=0.22; CI95%: 0.03-0.40), peer pressure resistance (RR=2.05; CI95%: 1.24-3.42), drug use (RR=0.81; CI95%: 0.64, 1.02), marijuana use (RR=0.82; CI95%: 0.73, 0.92) and hard drug use (RR=0.45; CI95%: 0.24-0.85). (3) Skills vs knowledge: No differences are evident.(4) Skills vs affective: Skills-based interventions are only better than affective ones in self-efficacy (WMD=1.90; CI95%: 0.25, 3.55). (5) Affective vs usual curricula: Affective interventions improve drug knowledge (SMD=1.88; CI95%: 1.27, 2.50) and decision making skills (SMD=1.35; CI95%: 0.79, 1.9). (6) Affective vs knowledge: Affective interventions improve drug knowledge (SMD=0.60; CI95%: 0.18,1.03), and decision making skills (SMD=1.22; CI95%: 0.33, 2.12). Results from CPSs: No statistically significant results emerge from CPSs. AUTHORS' CONCLUSIONS: Skills based programs appear to be effective in deterring early-stage drug use. The replication of results with well designed, long term randomised trials, and the evaluation of single components of intervention (peer, parents, booster sessions) are the priorities for research. All new studies should control for cluster effect.

Adolescent↗
PubMed2002

Cognitive rehabilitation for spatial neglect following stroke.

BACKGROUND: Unilateral spatial neglect is a failure to attend to one side of space. Various strategies have been used to treat these problems but evidence of their benefit has been lacking. OBJECTIVES: To determine the effects of cognitive rehabilitation for spatial neglect following stroke as measured on impairment and disability level assessments, and destination on discharge from hospital. To determine whether any effects persist at follow-up assessment. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched February 2001), MEDLINE (1966-December 2000), EMBASE (1980-February 2001), CINAHL (1983-January 2001), PSYCLIT and CLINPSYCH (1974-February 2001). We handsearched relevant journals, screened reference lists from relevant articles and tracked citations using SCISEARCH. SELECTION CRITERIA: Controlled trials of cognitive rehabilitation for spatial neglect in stroke. Studies with mixed patient groups were excluded unless more than 75% of their sample were stroke patients or separate stroke data were available for stroke patients. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials, extracted data, and assessed trial quality. MAIN RESULTS: We included 15 studies with 400 participants. A large number of different outcome measures were reported. Only six studies included a measure of disability and only four (111 participants) investigated persisting effects on any outcome. There was evidence that cognitive rehabilitation resulted in significant and persisting improvements in performance on impairment level assessments, although this varied depending on the test used. There was insufficient evidence to confirm or exclude an effect of cognitive rehabilitation at the level of disability or on destination following discharge from hospital. REVIEWER'S CONCLUSIONS: There is some evidence that cognitive rehabilitation for spatial neglect improves performance on some impairment level tests but its effect on disability is unclear. Further well-designed RCTs are warranted as well as basic research to develop valid outcome measures.

Cognitive Behavioral Therapy↗