Showing papers by "Cochrane Collaboration published in 2000"

Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library

Abstract: Peto estimates that current cigarette smoking will cause about 450 million deaths worldwide in the next 50 years Reducing current smoking by 50% would avoid 20–30 million premature deaths in the first quarter of the century and about 150 million in the second quarter1 Preventing young people from starting smoking would cut the number of deaths related to tobacco, but not until after 2050 Quitting by current smokers is therefore the only way in which tobacco related mortality can be reduced in the medium term There is evidence that some form of treatment aids an increasing number of successful attempts to quit2 This review aims to summarise evidence for the effectiveness of the available interventions #### Summary points Advice from doctors, structured interventions from nurses, and individual and group counselling are effective interventions Generic self help materials are no better than brief advice but more effective than doing nothing; personalised materials are more effective than standard materials All forms of nicotine replacement therapy are effective The antidepressants bupropion and nortriptyline increased quit rates in a small number of trials; the usefulness of the antihypertensive drug clonidine is limited by side effects Anxiolytics and lobeline are ineffective The effectiveness of aversion therapy, mecamylamine, acupuncture, hypnotherapy, and exercise is uncertain The Cochrane Tobacco Addiction Review group identifies and summarises the evidence for interventions to reduce and prevent tobacco use; it produces and maintains systematic reviews to inform policymakers, clinicians, and individuals wishing to stop smoking Twenty systematic reviews are available in the Cochrane Library and have contributed to the evidence base for smoking cessation guidelines3 Details of the methods and results of each review are available in the Cochrane Library (abstracts at wwwupdate-softwarecom/ccweb/cochrane/revabstr/g160indexhtm) The reviews summarise results from randomised controlled trials with at least six …

Non-steroidal anti-inflammatory drugs.

Abstract: Definition Non-steroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory, analgesic, and antipyretic effects and inhibit thrombocyte aggregation. The drugs have no documented effect on the disease process itself. Incidence/prevalence NSAIDs are widely used. Almost 10% of people in the Netherlands had used a non-aspirin NSAID in 1987; the overall use was 11 defined daily doses (see box) per 1000 persons a day.1 In Australia in 1994, overall use was 35 defined daily doses per 1000 persons a day, with 36% of the people receiving NSAIDs for osteoarthritis, 42% for sprain and strain or low back pain, and 4% for rheumatoid arthritis; 35% were aged over 60 years.2 Aims To reduce symptoms in rheumatic disorders; to avoid severe gastrointestinal adverse effects. Outcomes Primary outcomes: pain intensity, person's preference for one drug over another, global efficacy, and clinically significant gastrointestinal complications. Secondary outcomes: number of tender joints, perforation, gastrointestinal haemorrhage, dyspepsia, and ulcer detected by routine endoscopy. Defined daily dose : The assumed average daily dose for the main indication of a specified drug. The defined daily dose per 1000 population per day is an estimate of the proportion of that population receiving treatment with that drug. We searched Medline and the Cochrane Library in July 1999 for systematic reviews and randomised controlled trials (RCTs) that included at least 100 people. More than 100 meta-analyses and thousands of RCTs have compared various NSAIDs. Many trials are unpublished or published in sources that are not indexed in publicly available databases. The quality of the trials is variable and bias is common, both in the design and analysis of the trials, to such an extent that a systematic review identified false significant findings favouring new drugs over control drugs in 6% of trials.3 #### Interventions ##### Beneficial: NSAIDs in rheumatoid arthritis Misoprostol in high risk patients who …

Population-based study on incidence, risk factors, clinical complications and drug utilisation associated with influenza in the United Kingdom

Abstract: This large population-based study using the UK-based General Practice Research Database was conducted to quantify influenza-related physician visits, clinical complications of and risk factors for influenza, and related drug use in all age groups from 1991 to 1996. A total of 141,293 subjects who had one or more diagnoses of influenza or influenza-like illness during the study period as well as the same number of age-, sex-, practice and calendar time-matched controls were identified. Adults aged 15–64 years had the highest influenza incidence rate. The risk of getting influenza was particularly increased for subjects with chronic respiratory conditions (asthma or chronic obstructive pulmonary disease, odds ratio 1.65, 95% confidence interval 1.60–1.70). Subjects with influenza were more likely to have a diagnosis of clinical complications than control subjects (relative risk 3.4, 95% confidence interval 3.3–3.6). The risk of developing clinical complications was highest for children and was elevated for subjects with certain underlying chronic conditions. In absolute terms, otherwise healthy adults (15–64 years) accounted for the greatest proportion of all influenza-related physician visits as well as clinical complications in this study population. Of the 141,293 subjects with influenza, 83,911 (59.4%) received drugs on prescription. The most frequently prescribed drugs were antibiotics (45.2%), followed by antipyretics/analgesics (22.5%). Influenza patients were approximately six times more likely to use drugs on prescription than controls. This analysis may lead to further analyses on the economic impact of influenza and the contribution of different population groups to that burden.

Size and quality of randomised controlled trials in head injury: review of published studies

Abstract: Objective: To assess whether trials in head injury are large enough to avoid moderate random errors and designed to avoid moderate biases. Design: All randomised controlled trials on the treatment and rehabilitation of patients with head injury published before December 1998 were surveyed. Trials were identified from electronic databases, by hand searching journals and conference proceedings, and by contacting researchers. Data were extracted on the number of participants, quality of concealment of allocation, use of blinding, loss to follow up, and types of participants, interventions, and outcome measures. Results: 279 reports were identified, containing information on 208 separate trials. The average number of participants per trial was 82, with no evidence of increasing size over time. The total number of randomised participants in the 203 trials in which size was reported was 16 613. No trials were large enough to detect reliably a 5% absolute reduction in the risk of death or disability, and only 4% were large enough to detect an absolute reduction of 10%. Concealment of allocation was adequate in 22 and inadequate or unclear in 25 of the 47 (23%) in which it was reported. Of 126 trials assessing disability, 111 reported the number of patients followed up, and average loss to follow up was 19%. Of trials measuring disability, 26 (21%) reported that outcome assessors were blinded. Conclusions: Randomised trials in head injury are too small and poorly designed to detect or refute reliably moderate but clinically important benefits or hazards of treatment. Limited funding for injury research and unfamiliarity with issues of consent may have been important obstacles.

Low protein diets delay end‐stage renal disease in non‐diabetic adults with chronic renal failure

Abstract: protein intake to retard or even halt the development Background. The objective of this study was to deter- of non-specific glomerular or interstitial lesions, and mine the efficacy of low protein diets in delaying the hence, the progression of patients towards end-stage need to start maintenance dialysis based on an analysis renal disease. Despite the large number of studies on of published literature. dietary interventions that were performed a few decMethods. The search strategy involved a Medline and ades ago, it is still unclear if patients should limit their Embase search from January 1966 through to June protein intake and if so, to what extent nutritional 1999, congress abstracts (American Society of behaviour should be changed during chronic renal Nephrology since 1990, European Dialysis Transplant failure. Most of the clinical studies were designed to Association since 1985, International Society of test the efficacy of reducing protein intake on surrogate Nephrology since 1987) and direct contacts with invest- renal function outcomes, such as serum creatinine igators. The selection criteria included randomized increase or creatinine clearance decrease over time. trials comparing two different levels of protein intake Unfortunately, changing protein intake will modify all in adult patients suffering from moderate to severe creatinine markers and, therefore, no valid conclusions renal failure, followed for at least 1 year. Patients with can be drawn from these studies. Although a few trials diabetic nephropathy were excluded. Seven trials were used what are considered as gold standard renal funcselected from 40 studies since 1975. A total of 1494 tion assessments such as glomerular filtration rate patients were analysed: 753 had received reduced pro- (GFR), the results from these studies have been contein intake and 741 a higher protein intake. The flicting. Moreover, GFR is not a clinical outcome. numbers of ‘renal deaths’ (defined as the need for starting dialysis, the death of a patient or kidney transplant during the trial ) were collected. Results. 242 renal deaths were recorded, 101 in the Methods low protein diet and 141 in the higher protein diet group, giving an odds ratio of 0.61 with a 95% confid- The objective of this review was to determine the efficacy of ence interval of 0.46 to 0.83 (P=0.006). low protein diets in preventing the natural progression of Conclusion. Reducing protein intake in patients with chronic renal failure towards end-stage renal disease and chronic renal failure reduces the occurrence of renal therefore delaying the need for starting maintenance dialysis. death by about 40% as compared with larger or For this purpose, we defined the ‘renal death’ outcome, i.e. unrestricted protein intake. The optimal level of protein the number of deaths or number of patients who will start intake cannot be confirmed from these studies. dialysis or will receive a kidney transplant during the observa

Comparison of long versus short duration of anticoagulant therapy after a first episode of venous thromboembolism: a meta-analysis of randomized, controlled trials

Abstract: . Pinede L, Duhaut P, Cucherat M, Ninet J, Pasquier J, Boissel JP (Hopital Edouard Herriot and Unite de Pharmacologie Clinique, Lyon, France). J Intern Med 2000; 247: 553–562. Objective. To assess the length of oral anticoagulant therapy (short versus long duration) after a first episode of venous thromboembolism (VTE). Design. Meta-analysis of randomized controlled trials, comparing two durations of anticoagulation, identified in 1999 by a computerized search of the Cochrane Controlled Trial Register, Medline and Embase, completed by an extensive review of the references of pertinent articles. Setting and subjects. The meta-analysis was performed on literature data. Seven published controlled trials were included. Relative risks with 95% confidence intervals were computed using the relative risk logarithm method. Statistical significance was set up at 0.01 for the test of association. Main outcome measures. Outcomes are major haemorrhage and recurrence after a 12-month follow-up. Results. For the recurrence end-point (sample size of 2304 patients), a duration treatment of 12–24 weeks seems preferable to a 3–6 week regimen, with a relative risk (RR) of 0.60 (95% CI: 0.45–0.79, P < 0.001). For the major haemorrhage end-point (1823 patients), the RR is not significantly different from 1 (RR = 1.43, 95% CI: 0.51–4.01, P = 0.5). The results were similar for the subgroup ‘permanent risk factors’ or ‘idiopathic VTE’ (RR for recurrence = 0.48, 95% CI: 0.34–0.68, P < 0.001). The tendency was similar, although not reaching statistical significance, for the ‘temporary risk factors’ subgroup (RR for recurrence = 0.34, 95% CI: 0.13–0.93, P = 0.035). Conclusions. After a first episode of VTE, a long-term treatment regimen allows a significant reduction in the incidence of recurrences without increasing the incidence of bleeding events.

Antibiotics for preventing respiratory tract infections in adults receiving intensive care.

Abstract: Background Pneumonia is an important cause of mortality in intensive care units. The incidence of pneumonia in such patients ranges between 7% and 40%, and the crude mortality from ventilator associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to infections, it has been shown to contribute to mortality in intensive care units independently of other factors that are also strongly associated with such deaths. Objectives The objective of this review was to assess the effects of antibiotics for preventing respiratory tract infections and overall mortality in adults receiving intensive care. Search strategy We searched Medline, the Cochrane Acute Respiratory Infections Group trials register, proceedings of scientific meetings and reference lists of articles from January 1984 to December 1999. We also contacted investigators in the field. Selection criteria Randomised trials of antibiotic prophylaxis for respiratory tract infections and deaths among adult intensive care unit patients. Data collection and analysis Investigators were contacted for additional information. At least two reviewers independently extracted data and assessed trial quality. Main results Overall 33 trials involving 5727 people were included. There was variation in the antibiotics used, patient characteristics and risk of respiratory tract infections and mortality in the control groups. In 16 trials (involving 3361 patients) that tested a combination of topical and systemic antibiotic, the average rates of respiratory tract infections and deaths in the control group were 36% and 30% respectively. There was a significant reduction of both respiratory tract infections (odds ratio 0.35, 95% confidence interval 0.29 to 0.41) and total mortality (odds ratio 0.80, 95% confidence interval 0.69 to 0.93) in the treated group. On average 5 patients needed to be treated to prevent one infection and 23 patients to prevent one death. In 17 trials (involving 2366 patients) that tested topical antimicrobials the rates of respiratory tract infections and deaths in the control groups were 28% and 26% respectively. There was a significant reduction of respiratory tract infections (odds ratio 0.56, 95% confidence interval 0.46 to 0.68) but not in total mortality (odds ratio 1.01, 95% confidence interval 0.84 to 1.22) in the treated group. Reviewer's conclusions A combination of topical and systemic prophylactic antibiotics can reduce respiratory tract infections and overall mortality in adult patients receiving intensive care. The design of the trials included in this systematic review does not allow to assess whether or not the treatment leads to antimicrobial resistance. Trials with different design are warranted to reliably address this question.

Method for enforcing workflow processes for website development and maintenance

Abstract: A method for enforcing workflow process for website development and maintenance (104). Development and maintenance of a website may include the concerted efforts of plural person (102). So that the work progresses in a predictable and orderly fashion, tasks are assigned and performed in accordance with a workflow. The workflow is a serial order, in parallel with each other or in combinations of serial and parallel. To enforce a particular workflow, the present invention provides an environment that constrains work to progress according to the workflow. An administrator (120), such as a 'webmaster', develops a workflow file that dictates how the efforts of users (or 'contributors') should progress. Accordingly, the webmaster has increased control over the processes by which the website is developed and updated. As a result, website development proceeds efficiently even where many persons are involved in the effort (124).

Should journals publish systematic reviews that find no evidence to guide practice? Examples from injury research.

Abstract: Many systematic reviews are inconclusive and reinforce the message that there is clinical uncertainty. Phil Alderson and Ian Roberts argue that journals should make a point of publishing such reviews rather than waiting for reviews that show marked benefit or harm. Some experts disagree, however, but we failed to persuade them to commit their views to print. Studies with dramatic findings make interesting reading. Journal editors understandably want to publish articles that their readers will enjoy. This is one cause of publication bias, where research with less dramatic results tends to be published in journals with a smaller circulation, if indeed it is published at all. Systematic reviews are no less vulnerable to this bias than other types of research. Should journals resist this pressure and make a point of publishing systematic reviews even if all they show is continuing clinical uncertainty? The answer will depend on the importance we attach to demonstrating uncertainty in medical practice. #### Summary points Denying uncertainty does not benefit patients and may increase health service costs More large scale randomised trials need to be conducted based on the “uncertainty principle” Systematic reviews with more dramatic results tend …

Method and apparatus for deploying data among data destinations for website development and maintenance

Abstract: A method and apparatus are provided for dynamically organizing and tracking website content during its deployment (100). Organizing and tracking may be done internally to a website development system during development and externally to outside destinations such as production servers (120) that provide access to websites via the Internet or intranet (124). The method of internal deployment includes the process of deploying data among workstations (102), storage areas (104), such as a backing store, staging areas, editing areas and other internal areas during the development of website content. According to the invention, a tracking system is able to track such changes as the content is being created, including information regarding their source and history. The method of external deployment includes different schemes for deploying the finished website content to one or more destinations, such as production servers. The invention also includes a method and apparatus for creating templates for use in deploying data, both internally and externally.

Interventions for promoting adherence to tuberculosis management

Abstract: Background Up to half the people with tuberculosis do not complete their treatment. Strategies to improve adherence to diagnostic and treatment regimens are therefore important. Objectives To assess the effects of various interventions aimed at promoting adherence to anti-tuberculosis treatment and completion of TB diagnostic protocols. Search strategy We searched the Cochrane Controlled Trials Register, the Cochrane Infectious Diseases Group trials register, Medline, Embase, Lilacs and reference lists of articles. We contacted experts in the field. Selection criteria Randomised and quasi-randomised trials of interventions to promote adherence with curative or preventive chemotherapy and diagnostic protocols for tuberculosis. Data collection and analysis Two reviewers independently assessed trial quality and extracted data. Main results Fourteen trials were included. Reminder cards sent to defaulters, a combination package of a monetary incentive and health education and more supervision of clinic staff increased the number of people completing their tuberculosis treatment. Intensive counselling/education did not help in one study. Direct observation showed better clinical outcomes in one study, and no difference in another. Return to the clinic for reading of a tuberculin skin test was enhanced by monetary incentives, assistance by lay health workers, contracts and telephone prompts but not by health education. Authors' conclusions We have found evidence of benefit for a number of specific interventions to improve adherence to anti-tuberculous therapy and completion of diagnostic protocols. These should be implemented by health care providers where appropriate to local circumstances. Future studies in low income countries are a priority and should measure adherence and clinical outcomes. This review summarises trials up to 2000. It is being replaced by a series of reviews on particular intervention strategies. The details are in the 'Published notes' section.

Psychosocial interventions for schizophrenia

Abstract: This paper summarises the research evidence presented in a recent issue of Effective Health Care on psychosocial interventions used in the management of schizophrenia.1 This is the second bulletin on the management of schizophrenia and, as with the previous issue on drug treatments,2 draws upon evidence from systematic reviews carried out by the Cochrane Schizophrenia Group.3 For schizophrenia, as with any potentially disabling illness, comprehensive care involves a combination of pharmacological treatments, the provision of ongoing support, valid information, and treatment or rehabilitative strategies. This review divides non-pharmacological interventions into three treatment strategies: (1) those that seek primarily to support or educate; (2) those that provide specific skills training; and (3) those that are problem or symptom focused. Most of the information contained in this bulletin has been extracted from Cochrane reviews. These reviews have been acknowledged in the recent National Service Framework for Mental Health as important sources of information for clinical decision making.4 As with the preceding bulletin on drug treatments,2 efforts have been made to present clinically meaningful data. For a more detailed discussion of each area the reader is referred to the original reviews which are regularly updated in the Cochrane Library.5 Unless stated otherwise, patients in the studies of non-pharmacological interventions are also being prescribed medication. Most of the trial participants were adults and no studies focused specifically on the care of adolescents or the elderly. ### SUPPORTIVE EDUCATIONAL INTERVENTIONS Patients with schizophrenia and their carers should expect support and have a right to be well informed about the illness.6 Supportive educational packages aim to provide structure to what may otherwise be a haphazard process and can be implemented by any trained person.7 Support involves helping everyone to come to terms with a potentially stigmatising and disabling major mental illness, and …

Current Controlled Trials: an opportunity to help improve the quality of clinical research

Abstract: Some problems with the quality of controlled clinical trials can be addressed by following these procedures: registering all trials at inception; using systematic reviews to inform the design of new studies; posting and obtaining feedback on preprints; reporting all well conducted trials, regardless of their results; reducing biased and inefficient assessment of reports submitted for publication; publishing sufficiently detailed reports; linking trial reports to relevant external information; providing readier access to reports; and reviewing and amending reports after initial publication. The launch of a new range of electronic journals by Current Controlled Trials offers an opportunity to contribute to progress in these ways.

Single dose oral dihydrocodeine for acute postoperative pain

Abstract: Background This is an updated version of the original Cochrane review published in Issue 2, 2000. Dihydrocodeine is a synthetic opioid analgesic developed in the early 1900s. Its structure and pharmacokinetics are similar to that of codeine and it is used for the treatment of postoperative pain or as an antitussive. It is becoming increasingly important to assess the relative efficacy and harm caused by different treatments. Relative efficacy can be determined when an analgesic is compared with control under similar clinical circumstances.

Single dose oral piroxicam for acute postoperative pain

Abstract: Background This is an updated version of the original Cochrane review published in Issue 2, 2000. Piroxicam is a non-steroidal anti-inflammatory drug (NSAID) with analgesic properties, and is used mainly for treating rheumatic disorders. Some drugs have been directly compared against each other within a trial setting to determine their relative efficacies, whereas other have not. It is possible, however, to compare analgesics indirectly by examining the effectiveness of each drug against placebo when used in similar clinical situations. Objectives To determine the analgesic efficacy and adverse effects of single-dose piroxicam compared with placebo in moderate to severe postoperative pain. To compare the effects of piroxicam with other analgesics. Search methods Published studies were identified from systematic searching of MEDLINE, Biological Abstracts, EMBASE, CENTRAL and the Oxford Pain Relief Database in December 2007. Additional studies were identified from the reference lists of retrieved reports. Selection criteria The following inclusion criteria were used: full journal publication, randomised placebo controlled trial, double-blind design, adult participants, postoperative pain of moderate to severe intensity at the baseline assessment, postoperative administration of oral or intramuscular piroxicam. Data collection and analysis Summed pain intensity and pain relief data were extracted and converted into dichotomous information to yield the number of participants obtaining at least 50% pain relief. This was used to calculate estimates of relative benefit and number-needed-to-treat-to-benefit (NNT) for one participant to obtain at least 50% pain relief. Information was collected on adverse effects and estimates of relative risk and number-needed-to-treat-to-harm (NNH) were calculated. Main results In this update no further studies were found. The original search identified three studies (141 participants) which compared oral piroxicam 20 mg with placebo and one (15 participants) compared oral piroxicam 40 mg with placebo. For single doses of piroxicam 20 mg and 40 mg the respective NNT for at least 50% pain relief were 2.7 (2.1 to 3.8) [95% confidence interval (CI)] and 1.9 (1.2 to 4.3) [95% CI] compared with placebo over four to six hours in moderate to severe postoperative pain. The reported incidence of adverse effects was no higher with piroxicam (20 mg or 40 mg) than with placebo. No further additional studies were found in the updated search. Authors' conclusions Piroxicam appears to be of similar efficacy to other NSAIDs and intramuscular morphine 10 mg when used as a single oral dose in the treatment of moderate to severe postoperative pain.

Somatostatin or octreotide for acute bleeding oesophageal varices.

Abstract: BACKGROUND Somatostatin and its derivative, octreotide, are often used for emergency treatment of bleeding oesophageal varices in patients with cirrhosis of the liver. The placebo controlled trials have shown varying results, however, and their power has been quite low. An updated systematic review of a previously published meta-analysis was therefore performed. OBJECTIVES To study whether somatostatin or octreotide improve survival or reduce the number of blood transfusions in patients with suspected or verified acute or recently bleeding oesophageal varices. SEARCH STRATEGY MEDLINE and The Cochrane Library are searched every three months. Reference lists of articles and authors. SELECTION CRITERIA All randomised trials comparing somatostatin or octreotide with placebo or no treatment in patients suspected of acute bleeding from oesophageal varices. DATA COLLECTION AND ANALYSIS The effect variables extracted were: mortality, number of blood transfusions, number with balloon tamponade, number with initial haemostasis and number with rebleeding. Intention to treat analyses were conducted; a random effects analysis was preferred if there was significant heterogeneity between the trials (p<0.10). MAIN RESULTS The meta-analysis comprised 820 patients. The active drugs had no effect on survival; a total of 91 patients died in the experimental groups vs 85 patients in the control groups (odds ratio 1.04, 95% confidence interval (CI) 0.74 to 1.46). The number of transfusions was less with drugs, the difference between experimental and control therapy was 1.2 units of blood products saved per patient (95% CI 0. 8 to 1.6). There were no significant differences in use of balloon tamponade (odds ratio 0.59, 95% CI 0.21 to 1.70), number of patients failing initial haemostasis (odds ratio 0.66, 95% CI 0.32 to 1.37) or number with rebleeding (odds ratio 0.73, 95% CI 0.30 to 1.79). It should be noted, however, that the trials were heterogeneous with respect to these secondary variables. REVIEWER'S CONCLUSIONS The effect corresponded to one unit of blood saved per patient. This effect is small and treatment with these drugs in acute bleeding oesophageal varices is therefore of doubtful value. This does not suggest a need for further studies. On the other hand, the confidence interval for the effect on mortality was wide. Hence, a large placebo controlled trial is needed if one wishes to rule out the possibility that a worthwhile effect on mortality may have been overlooked.

Depot fluphenazine for schizophrenia.

Abstract: Background In the years after the discovery of oral antipsychotic medications, it became clear that there was a link between stopping medication and relapse of psychotic symptoms. A series of long-acting preparations was developed. These depot preparations, are frequently used for those who find taking oral medication on a regular basis difficult or unacceptable. However, it has been a consistent concern that any reduction in relapse rate afforded by the depot preparations may be offset by an increase in undesirable side effects. There is one oral preparation and two depot forms (enanthate (Moditen) and decanoate (Modecate)). The decanoate form is more frequently used but both versions were reviewed in this work. Objectives To compare depot fluphenazine medication to oral fluphenazine for treatment of schizophrenia. Search strategy Electronic searches of Biological Abstracts, CSG's Register, EMBASE, LILACS, MEDLINE, PsycLIT, SCISEARCH, hand searching the references of all identified studies and contacting the manufacturers of the compounds. Selection criteria All randomised clinical trials that compared fluphenazine enanthate or fluphenazine decanoate to oral fluphenazine for people with schizophrenia or other psychoses were included. Data collection and analysis One reviewer (CEA) inspected study citations and then the second reviewer (ME) independently inspected 20% of citations to ensure reliability. Full reports of the studies of agreed relevance were obtained and data extracted in the same manner by the authors. Trials were allocated to three quality categories, as described in the Cochrane Collaboration Handbook. Data were analysed on an intention-to-treat basis, and, where possible, parametric continuous data were presented. Tests for heterogeneity were undertaken. Main results Data were very limited. There was no difference between fluphenazine hydrochloride and its depot form for outcomes such as global impression of functioning, relapse/re-hospitalisation, poor initial response to treatment, leaving the study early, depressed mood / suicide and side effects such as movement disorders, uncomfortable dry mouth, sleep problems and weight gain were equally common in both groups. Direct measures of mental state, social functioning and satisfaction with care were either not measured or presented in such as way as to make any analysis impossible. Reviewer's conclusions All six included studies relate to people with schizophrenia who are already stable on oral fluphenazine or seem contented to stay in the studies. How the data from this review relate to everyday psychiatric practices, where compliance with medication is more problematic, is debatable. The use of depot fluphenazine continues to be based on clinical judgement rather than evidence from methodical evaluation within trials. A large pragmatic randomized controlled trial is long overdue.

Identifying systematic reviews: key resources

Abstract: How effective are antibiotics for treating patients with sore throat? The first choice of resource for the practitioner to answer a clinical effectiveness question such as this one should be a systematic review. By systematically searching, assessing, and summarising the research evidence by using rigorous methods, the best systematic reviews present a time saving distillation of the current state of knowledge. The number of systematic reviews has been growing and continues to grow rapidly. This growth has fortunately been accompanied by efforts to identify, collect, and present reviews in easy to access collections. This editorial presents a strategy for searching for systematic reviews of effectiveness by using a selection of the best of these collections. The first stage, and often the only necessary stage, in finding an up to date systematic review of the effects of health care interventions is to search the Cochrane Library .1 The Cochrane Database of Systematic Reviews (CDSR) in the Cochrane Library contains a unique, cumulative collection of full text systematic reviews that are valuable not only for their rigorous methods but also for their regular updates, which occur as new research evidence is published and in response to valid criticisms. If searchers are unable to find an up to date Cochrane review in the CDSR on their topic of interest, the Cochrane Library has summaries of other quality assessed reviews (including reviews of diagnostic tests) in the Database of Abstracts of Reviews of Effectiveness (DARE) and abstracts of technology assessments in the Health Technology Assessment (HTA) database. An initial search of the Cochrane Library can save much time and effort in searching other resources. Non-subscribers to the full Cochrane Library can search abstracts of Cochrane reviews together with DARE and HTA database records free on the NHS Centre for Reviews …

Antibiotic prophylaxis in intensive care units: meta-analyses versus clinical practice.

Abstract: Objective: At least 7 meta-analyses (MA) have been published since 1991 on the effectiveness of antibiotic prophylaxis in Intensive care units (ICU) patients, but controversy still remains about the overall effectiveness and risk-benefits profile of the treatment. This paper aims to summarise available data on effectiveness and discuss reasons why the controversy is still open and possible directions for future research.¶Design: Review of available published MA on the effectiveness of various regimens of antibiotic prophylaxis with particular emphasis on the results of the individual patient data analysis published in 1998.¶Setting: MA or randomised control trials (RCTs), published and unpublished, conducted anywhere in the world.¶Patients and participants: Unselected adult ICU populations included in studies, published and unpublished, comparing different forms of antibiotic prophylaxis.¶Main outcome measure: Respiratory tract infections (RTIs) – however defined in individual studies – and total mortality.¶Data sources: General information from the 7 MAs published between 1991 and 1999 and detailed information from the MA published in the British Medical Journal in 1998 that reported data on 5727 patients enrolled in 33 RCTs; access to individual patients data could be obtained from 25 of 33 RCTs and allowed a confirmatory individual patient MA on 4343 patients.¶Results: Pooled estimates from 16 RCTs (including 3361 patients) testing the effect of the topical and systemic antibiotic combination indicates a significant reduction of both RTIs (OR = 0.35, 95 % CI = 0.29–0.41) and total mortality (OR = 0.80, 95 % CI = 0.69–0.93). Five and 23 patients need to be treated to prevent one infection and one death, respectively, using this treatment. Pooled data from the 17 RCTs (including 2366 patients) testing the effect of a regimen based on topical antimicrobials indicated a statistically significant reduction in RTIs (OR = 0.57, 95 % CI = 0.46–0.69) but not in total mortality (OR = 1.01; 95 % CI = 0.84–1.22). Individual patient data analyses confirmed these results.¶Conclusions: After over 30 RCTs and seven MAs, there is strong evidence that antibiotic prophylaxis can reduce both RTIs and total mortality in ICUs patients in a statistically and clinically significant way. Concerns about the possible occurrence of antimicrobial resistance are not supported by available data but cannot, at the same time, be ruled out due to methodologic inadequacies of the studies carried out so far. Whether new trials are needed, and how they should be designed to answer the question of the potential for antibiotic resistance following widespread use of the treatment, are now the main issues to be settled. Convening an international panel of clinical experts and methodologists could be appropriate, in order to explore the best way to resolve the controversy that seems to be preventing the widespread use of a treatment that the best analysis of available data now indicates is effective.

Helping physicians to keep abreast of the medical literature: Medical and Philosophical Commentaries, 1773-1795.

Abstract: Conscientious physicians wishing to keep up to date with relevant information face a truly daunting task. Efforts to respond to this need are not new. More than two centuries ago, the first English...

Polyunsaturated fatty acid (fish or evening primrose oil) for schizophrenia.

Abstract: Background Limited evidence gives support to an hypothesis suggesting that the symptoms of schizophrenia may result from altered neuronal membrane structure and metabolism. The latter are dependent on blood plasma levels of certain essential fatty acids (EFAs) and their metabolites. Several studies have shown those with schizophrenia often have low levels of the particular EFAs necessary for normal nerve cell membrane metabolism. Objectives To review the effects of supplementing standard antipsychotic treatment with polyunsaturated fatty acids, whether essential (EFAs) or non-essential, for those with schizophrenia and, in recent updates to also evaluate the effects of EFA's as a sole antipsychotic treatment. To evaluate the relative efficacy of different types of fatty acid supplementation. Search strategy Relevant randomised trials were identified by searching the following electronic databases: Biological Abstracts (1985-1998), CINAHL (1982-1998), Cochrane Library (Issue 4, 1999), Cochrane Schizophrenia Group's Register (February 2000), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1998). In addition, reviewers searched references of included and excluded studies and contacted authors to identify further studies. Selection criteria All randomised clinical trials of polyunsaturated fatty acid supplementation to standard treatment or as primary intervention for schizophrenia (however defined) versus standard care. Data collection and analysis Reviewers evaluated data independently and analysed on an intention-to-treat basis. They assumed that people who left the study early or were lost to follow-up had no improvement. Where possible and appropriate relative risk (RR) and their 95% confidence intervals (CI) were calculated. The number needed to treat (NNT) was estimated. For continuous data weighted mean differences (WMD) and their 95% confidence intervals were calculated. Data were inspected for heterogeneity and publication biases. Main results Four relatively small trials (total n=204) showed low levels of loss to follow up and adverse effects for those taking essential fatty acids. Early results from a few trials suggest a positive effect of eicosapentaenoic acid (EPA) over placebo for scale-derived mental state outcomes. The data, however, is limited making these results difficult to analyse and interpret with confidence. A single small study (n=30) investigated the value of using EPA as sole treatment for people hospitalised for relapse. Results suggest that EPA may help one third of people avoid instigation of standard antipsychotic drugs for 12 weeks (RR 0.6, CI 0.4-0.91). There were no clear effects of primrose oil (omega-6) EFA supplementation. Reviewer's conclusions All data are preliminary, but results look encouraging for fish oil. EPA does not seem harmful, may be acceptable to people with schizophrenia and have moderately positive effect. A further trial is soon to be reported from the USA and more are underway or planned in the South Africa and Norway. Considering that EPA may be an acceptable intervention, large, long simple studies reporting clincially meaningful data should be anticipated.

Chronische lage rugpijn: oefentherapie, multidisciplinaire programma's, NSAiD's, rugscholing en gedragstherapie effectief en tractie niet effectief; resultaten van systematische reviews

Abstract: Objective. To inventory the current state of the art regarding the effectiveness of conservative treatment of chronic low back pain. Design. Systematic reviews. Method. The relevant literature from the period January 1966-September 1999 was retrieved via Medline, Embase, PsychLit and the Cochrane Library and via reference lists in the articles found. The methodological quality of the studies was assessed using criteria for internal validity. On the basis of the number of examinations, their quality and the consistency of the findings, conclusions were subdivided into four levels of strength of scientific evidence. Results. There was strong evidence that exercise therapy and multidisciplinary treatment programmes were effective in chronic low back pain, and moderate evidence that non-steroidal anti-inflammatory drugs (NSAIDs), back schools and behavioural therapy were effective in chronic low back pain. There was also strong evidence that traction was not effective in chronic low back pain. Strong evidence for effectiveness of many other commonly used interventions was lacking.