Die 5 Minuten Evidenz - Cochrane Ausgabe 1/2009

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Ausgabe 1/2009 der Cochrane Library

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Chirurgie

Antimicrobial prophylaxis for colorectal surgery  

182 Studien (n=30.880) mit 50 differenten Antibiotika
Antibiotics covering aerobic and aerobic bacteria should be delivered orally and intravenously prior to colorectal surgery.  Antibiotics delivered within this framework will reduce the risk of postoperative SWI by at least 75%. 

Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids   
12 Studien (n=1142)
A tendency for equal efficacy. Ligasure technique results in significantly less immediate postoperative pain

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis 
11 Studien (n=607)
The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable.

Vascular occlusion for elective liver resections 
5 Studien (n=166), hohes Risiko für Bias
The blood loss was significantly lower in vascular occlusion compared with no vascular occlusion.

Methods of vascular occlusion for elective liver resections 
10 Studien (n=657), hohes Risiko für Bias
In elective liver resection, hepatic vascular occlusion cannot be recommended over portal triad clamping.

Techniques for liver parenchymal transection in liver resection  
7 Studien (n=556)
There was no clinically or statistically significant difference in the operating time between sharp dissection and clamp-crush techniques. Clamp-crush technique is two to six times cheaper than the other methods depending upon the number of surgeries performed each year.

Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion  
4 Studien (n=271)
Currently, there is no evidence to suggest a protective effect of ischaemic preconditioning in non-cirrhotic patients undergoing liver resection under continuous vascular occlusion.

Palliative cytoreductive surgery versus other palliative treatments in patients with unresectable liver metastases from gastro-entero-pancreatic neuroendocrine tumours
Keine RCTs zu finden

Virtual reality training for surgical trainees in laparoscopic surgery   
23 trials mit 612 Patienten
Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training.

Robot assistant for laparoscopic cholecystectomy   
5 trials (all of high risk of bias) mit 453 Patienten
Although robot-assisted laparoscopic cholecystectomy appears safe, there seems to be no significant advantages over human-assisted laparoscopic cholecystectomy. We were unable to identify trials comparing one type of robot assistant versus another.

Cholecystectomy for gallbladder polyp   
Keine RCTs verfügbar
  
Cholecystectomy for suspected gallbladder dyskinesia    
1 Studie mit 21 Patienten, 11 mit cholecystectomy und 10 ohne Op als kontrolle
Keine verlässliche Aussage möglich

Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery 
6 Studien zu hyaluronic acid/carboxymethyl membrane (HA/CMC)
Evidence that the use of HA/CMC membrane reduces incidence, extent and severity of adhesions. There is no evidence that the incidence of intestinal obstruction or need for operative intervention is reduced.

Pre and peri-operative erythropoeitin for reducing allogeneic blood transfusions in colorectal cancer surgery.  
4 Studien
There is no sufficient evidence to date to recommend pre and peri-operative erythropoietin use in colorectal cancer surgery.

Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer    
4 Studien
The addition of chemotherapy to preoperative RT significantly increased grade III and IV acute toxicity (OR 1.68-10, P = 0.002) while no differences were observed in postoperative morbidity or mortality.

Prolonged thromboprophylaxis with Low Molecular Weight heparin for abdominal or pelvic surgery 
4 Studien
Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery.

Resorbable versus titanium plates for facial fractures   
Keine verwertbaren Studien, einige abgebrochen
The findings of this review, based on the results of the aborted trials, do not suggest that resorbable plates are as effective as titanium plates.

Steroid avoidance or withdrawal for kidney transplant recipients 
30 Studien (n=5949)
This review confirms that steroid avoidance and steroid withdrawal strategies in kidney transplantation are not associated with increased mortality or graft loss despite an increase in acute rejection.

Thoracic stent graft versus surgery for thoracic aneurysm 
Keine verwertbaren Studien

Decompressive surgery for treating nerve damage in leprosy
2 RCTs (n=88)
No significant added benefit of surgery over steroid treatment alone

Neurologie Depression, Nerven, Psychose

Combined psychotherapy plus benzodiazepines for panic disorder  
3 Studien
Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.

Olanzapine in long-term treatment for bipolar disorder 
5 Studien, n=1165
Though based on a limited amount of information, there is evidence that olanzapine may prevent further mood episodes in patients who have responded to olanzapine during an index manic or mixed episode and who have not previously had a satisfactory response to lithium or valproate. However, notwithstanding these positive results, the current evidence is stronger for lithium as first line maintenance treatment of bipolar disorder.

Benzodiazepines for delirium  
1 Studie
No adequately controlled trials could be found to support the use of benzodiazepines in the treatment of non-alcohol withdrawal related delirium among hospitalised patients.

Acupuncture for tension-type headache   
11 RCTs, n=2317
In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.

Psychological treatments for the management of irritable bowel syndrome 
25 Studien 
Except for a single study, these therapies are not superior to placebo and the sustainability of their effect is questionable.

Psychosocial interventions for reducing fatigue during cancer treatment in adults
27 Studien, n=3324
There is limited evidence that psychosocial interventions during cancer treatment are effective in reducing fatigue. At present, psychosocial interventions specifically for fatigue are a promising type of intervention.

Pharmacotherapy and psychotherapy for body dysmorphic disorder  
4 RCT, n=169
Results from the small number of available RCTs suggest that SRIs and CBT may be useful in treating patients with BDD.

Dance therapy for schizophrenia  
1 Studie, n=45
There is no evidence to support - or refute - the use of dance therapy in this group of people.

Amfetamine for attention deficit hyperactivity disorder in people with intellectual disabilities  
1 Studie
There is very little evidence for the effectiveness of amfetamine for ADHD in people with ID . Prescribing in this population is based on extrapolation of research in people without ID.

Anticholinergics for urinary symptoms in multiple sclerosis   
3 Studien
From the available evidence we cannot advocate the use of anticholinergics in MS.

Orthotic devices after stroke and other non-progressive brain lesions 
14 Studien, n=429
A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated.

Drug treatment for spinal muscular atrophy type I  
1 kleine Studie
No drug treatment for SMA type I has been proven to have significant efficacy.
    
Drug treatment for spinal muscular atrophy types II and III    
4 Studien
There is no proven efficacious drug treatment for SMA type II and III.

Decompressive surgery for treating nerve damage in leprosy  
2 RCTs (n=88)
No significant added benefit of surgery over steroid treatment alone

Corticosteroid injection for trigger finger in adults 
2 RCTs (n=63)
The effectiveness of local corticosteroid injections was studied in only two small randomized controlled trials of poor methodological quality. Both studies showed better short-term effects of corticosteroid injection combined with lidocaine compared to lidocaine alone on the treatment success outcome.

Treatment for familial amyotrophic lateral sclerosis/motor neuron disease   
4 Studien, n=863
There was no statistical evidence for a different response to treatment in patients with familial ALS/MND compared to those with sporadic ALS/MND.

Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis.  
2 Studien, n=80
There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment.

Interferon Beta for Primary Progressive Multiple Sclerosis  
2 RCTs, n=123
Limited data on the effect of ß-interferon treatment on PPMS exists

Very early versus delayed mobilisation after stroke    
1 Studie,n=71
We found insufficient evidence to support or refute the efficacy of routine very early mobilisation after stroke, compared with conventional care.

Cognition

Advance treatment directives for people with severe mental illness  
2 Studien, n=321
There are too few data available to make definitive recommendations.

Donepezil for dementia in people with Down syndrome    
1 Studie, n=30
To date there is only one small randomised controlled study on the effect of donepezil.
Galantamine for dementia in people with Down syndrome  
Keine RCTs

Memantine for dementia in people with Down syndrome  
Keine RCTs

Rivastigmine for dementia in people with Down syndrome 
Keine RCTs

Driving assessment for maintaining mobility and safety in drivers with dementia   
Keine RCTs

Interventions for preventing critical illness polyneuropathy and critical illness myopathy   
Two trials examined the effects of intensive insulin therapy versus conventional insulin therapy. Eight hundred and twenty-five out of 2748 patients randomised, were included in the analysis.
Substantial evidence shows that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, duration of ICU stay and 180-day mortality. There was a significant associated increase in hypoglycaemia.

Diabetes

Individual patient education for people with type 2 diabetes mellitus 
9 Studien (n=1359)
This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. However, overall there did not appear to be a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months.

Metformin added to insulin therapy for type 1 diabetes mellitus in adolescents  
1 Studie, n=60
There is some evidence suggesting improvement of metabolic control in poorly controlled adolescents with type 1 diabetes, on addition of metformin to insulin therapy.

Frauen

Treatments for suppression of lactation   
46 Studien, n=5164
There is weak evidence that some pharmacologic treatments (most of which are currently unavailable to the public) are better than no treatment for suppressing lactation symptoms in the first postpartum week.

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer    
Post-operative radiotherapy for ductal carcinoma in situ of the breast 
5 Trials (N=1277)
Adjuvant platinum based chemotherapy is effective in prolonging the survival of the majority of patients who are assessed as having early stage epithelial ovarian cancer. However, even given the limits of sub-group analyses, there is strong evidence that optimal surgical staging identifies patients who have either little or nothing to gain from adjuvant chemotherapy.

First line chemotherapy in low risk gestational trophoblastic neoplasia 
8 Studien, n = 769
The authors conclude that "pulsed" dactinomycin is superior to weekly parenteral methotrexate at the reported dosages. However, the authors believe that rigorously designed, multicentred, randomised double-blind trials are required to evaluate other combinations of chemotherapy regimens, most importantly "pulsed" dactinomycin with the widely used 8-day methotrexate-folinic acid.

Antibiotics for mastitis in breastfeeding women  
2 kleine Studien
There is insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis.

Chinese herbal medicine for premenstrual syndrome 
2 Studien (n=549)
One of the identified trials was well designed and reported on the effectiveness of Jingqianping in the treatment of premenstrual syndrome Qiao 2002. However, currently there is insufficient evidence to support the use of chinese herbal medicine for PMS and further, well controlled, trials are needed before any final conclusions could be drawn.

Hormone therapy for endometriosis and surgical menopause 
2 Studien, n=193
Hormone replacement therapy for women with endometriosis in post-surgical menopause could result in pain and disease recurrence. However, the evidence in the literature is not strong enough to suggest depriving severely symptomatic patients from this treatment. There is a need for more randomised controlled studies.

Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour  
1 Studie, n= 513
When compared with placebo, atosiban did not reduce preterm birth before 37 weeks (risk risk (RR) 0.89; 95% confidence intervals (CI) 0.71 to 1.12), 32 weeks (RR 0.85; 95% CI 0.47 to 1.55), or 28 weeks (RR 0.75; 95% CI 0.28 to 2.01).

Paracervical local anaesthesia for cervical dilatation and uterine intervention  
17 Studien, n= 1855
No technique provided reliable pain control in the 17 included studies. Some studies reported that women experienced severe pain (mean scores of 7 to 9 out of 10) during uterine intervention, irrespective of the analgesic technique used. We concluded that the available evidence fails to show whether paracervical block is inferior, equivalent or superior to alternative analgesic techniques, in terms of efficacy and safety, for women undergoing uterine interventions.

Postnatal parental education for optimizing infant general health and parent-infant relationships   
14 Studien, n=2934
Of the 14 included studies, education tested included: four on infant sleep enhancement, four on infant behaviour, two on general post-birth health, three on infant safety, and one on father involvement/skills with infants.
The benefits of educational programs to participants and their newborn infants remain unclear. Education on sleep enhancement appears to increase infant sleep although more and larger studies are needed to confirm this.

Prenatal education for congenital toxoplasmosis    
One cluster-randomized controlled trial (n=432)
Even though primary prevention of congenital toxoplasmosis is considered a desirable intervention, given the lack of related risks compared to secondary and tertiary prevention, its effectiveness has not been adequately evaluated. There is very little evidence from RCTs that prenatal education is effective in reducing congenital toxoplasmosis even though evidence from observational studies suggests it is.

Regimens of fetal surveillance for impaired fetal growth
1 Studie, n=167
The trial compared a twice-weekly surveillance regimen (biophysical profile, nonstress tests, umbilical artery and middle cerebral artery Doppler and uterine artery Doppler) with the same regimen applied fortnightly (both groups had growth assessed fortnightly).
In keeping with the more frequent monitoring, mean gestational age at birth was four days less for the twice-weekly surveillance group compared with the fortnightly surveillance group. Women in the twice-weekly surveillance group were 25% more likely to have induction of labour than those in the fortnightly surveillance group. The risk ratio was 1.25 (95% confidence interval 1.04 to 1.50).

Theory-based interventions for contraception 
26 Studien
Family planning researchers and practitioners could apply the relevant theories and effective interventions from HIV and STI prevention. More thorough use of single theories would help inform the field about what works. Better reporting is needed on research design and intervention implementation.

In vitro maturation in sub fertile women with polycystic ovarian syndrome undergoing assisted reproduction
Keine RCTs
There are no practice recommendations regarding IVM before IVF or ICSI for women with PCOS.

Interventions for treating painful sickle cell crisis during pregnancy  
Keine RCTs
This review found no randomised clinical trials on the safety and efficacy of interventions for treating painful sickle cell crisis during pregnancy.

Auge

Intravitreal steroids versus observation for macular edema secondary to central retinal vein occlusion   
Keine RCTs
There is inadequate evidence for the use of intravitreal steroids for CRVO-ME due to a paucity of RCTs and well-designed observational studies on the topic; therefore, it is still an experimental procedure.

Surgery for cataracts in people with age-related macular degeneration  
Keine RCTs
At this time, it is not possible to draw reliable conclusions from the available data to determine whether cataract surgery is beneficial or harmful in people with AMD. Physicians will have to make practice decisions based on best clinical judgement until controlled trials are conducted and their findings published.

Vision screening of older drivers for preventing road traffic injuries and fatalities   
No studies were found which met the inclusion criteria for this review.
Most countries require a vision screening test for the renewal of an individual's driver's license. There is, however, insufficient evidence to assess the effect of vision screening tests on subsequent motor vehicle crash reduction. There is a need to develop valid and reliable tools of vision screening that can predict driving performance.

Herzkreislauf, CVD

Transmyocardial laser revascularization versus medical therapy for refractory angina  
7 Studien (n=1137, davon 559 randomized to TMLR)
There is insufficient evidence to conclude that the clinical benefits of TMLR outweigh the potential risks. The procedure is associated with a significant early mortality.

Thrombophilia testing for prevention of recurrent venous thromboembolism   
Keine verwertbaren Studien
There are currently no randomized controlled trials or controlled clinical trials that have assessed the benefit(s) of testing for thrombophilia on the risk of recurrent VTE.  

Atmung

Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis
8 Studien (n=234)
We found no evidence to recommend the use of either nebulized or oral thiol derivatives in people with cystic fibrosis.

Oscillating devices for airway clearance in people with cystic fibrosis
30 Studien, n=708
There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy. More adequately-powered long-term randomised controlled trials are needed.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease 
6 Studien, n=219
Evidence from small studies of moderate methodological quality suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients after suffering an exacerbation.

Aktivität/Übergewicht

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18  
26 Studien
Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Interventions for preventing weight gain after smoking cessation  
Behavioual interventions of general advice only are not effective and may reduce abstinence.
Individualized interventions, very low calorie diets, and CBT may be effective and not reduce abstinence.
Exercise interventions are not associated with reduced weight gain at end of treatment, but may be associated with worthwhile reductions in weight gain in the long term,
Bupropion, fluoxetine, nicotine replacement therapy, and probably varenicline all reduced weight gain while being used. Although this effect was not maintained one year after quitting for bupropion, fluoxetine, and nicotine replacement, the evidence is insufficient to exclude a modest long-term effect.
The data are not sufficient to make strong clinical recommendations for effective programmes.

Low glycaemic index, or low glycaemic load, diets for diabetes mellitus   
11 Studien (n=402)
A low-GI diet can improve glycaemic control in diabetes without compromising hypoglycaemic events.

Krebs

Prophylactic antibiotics or G-CSF for the prevention of infections and improvement of survival in cancer patients undergoing chemotherapy 
2 RCT, N= 195
There is no evidence for or against antibiotics compared to G(M)-CSFs for the prevention of infections in cancer patients.

Radioiodine therapy for differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases 
Keine RCTs
The currently available evidence is insufficient to reliably assess the potential of radioiodine treatment for differentiated thyroid carcinoma with thyroglobulin positive and radioactive iodine negative metastases.

Treatment including anthracyclines versus treatment not including anthracyclines for childhood cancer  
RCTs for 5 types of tumour: acute lymphoblastic leukaemia (ALL) (n=3; 912 children), Wilms' tumour (n=1; 316 children), rhabdomyosarcoma/undifferentiated sarcoma (n=1; 413 children), Ewing's sarcoma (n=1; 94 children), and non-Hodgkin lymphoma (n=1; 284 children).
At the moment no evidence from RCTs is available which underscores the use of anthracyclines in ALL. However, it should be noted that "no evidence of effect", as identified in this review, is not the same as "evidence of no effect". For Wilms' tumour, rhabdomyosarcoma/undifferentiated sarcoma, Ewing's sarcoma, and non-Hodgkin lymphoma only 1 RCT was available and therefore, no definitive conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours. For other childhood cancers no RCTs were identified and therefore, no conclusions can be made about the antitumour efficacy of treatment with or without anthracyclines in these tumours.

Kinder     

Combination formoterol and inhaled steroid versus beta2-agonist as relief medication for chronic asthma in adults and children   
3 Studien (n=5905)
In mild asthma it is not yet known whether patients who use a budesonide/formoterol inhaler for relief of asthma symptoms derive any clinically important benefits. In more severe asthma, one study demonstrated a reduction in the risk of exacerbations that require oral corticosteroids with budesonide/formoterol for maintenance and relief in comparison with budesonide/formoterol for maintenance and terbutaline or formoterol for relief.

Oral lactoferrin for the treatment of sepsis and necrotizing enterocolitis in neonates 
Keine verwertbaren Studien

Beta-blockers for congestive heart failure in children 
3 Studien (n=203)
There are not enough data to recommend or discourage the use of beta-blockers in children with congestive heart failure.

Hematopoietic stem cell transplantation for children with sickle cell disease 
Keine verwertbaren Studien
Reports on the use of hematopoietic stem cell transplantation improving survival and preventing symptoms and complications associated with sickle cell disease are currently limited to observational and other less robust studies.

High versus low dose of initial thyroid hormone replacement for congenital hypothyroidism 
1 Studie, N= 47
There is currently only one randomised controlled trial evaluating the effects of high versus low dose of initial thyroid hormone replacement for CHT. There is inadequate evidence to suggest that a high dose is more beneficial compared to a low dose initial thyroid hormone replacement in the treatment of CHT.

Impact of tuberculosis preventive therapy on tuberculosis and mortality in HIV-infected children 
1 Studie
Isoniazid prophylaxis in HIV-infected children has the potential to play a major public health role by reducing TB incidence and death. As yet, however, data are insufficient to guide the duration of prophylaxis and to support its use in children using highly active antiretroviral therapy (HAART) and in those living in areas of low TB prevalence. Further studies are needed to assess whether TB preventive therapy is of benefit in all HIV-infected children, irrespective of use of antiretroviral treatment, the optimal duration of preventive therapy, or long-term adverse events.

Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age 
3 Studien
NP and NPC seem to be similar in effectiveness and safety when used in patients with LRTI. There is no single clinical sign or symptom that accurately identifies hypoxaemia. Studies identifying the most effective and safe oxygen delivery method are needed.

Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children   
20 Studien, n=13.102
Three to six days of oral antibiotics had comparable efficacy compared to the standard duration 10 day oral penicillin in treating children with acute GABHS pharyngitis. In countries with low rates of rheumatic fever, it appears safe and efficacious to treat children with acute GABHS pharyngitis with short duration antibiotics. In areas where the prevalence of rheumatic heart disease is still high, our results must be interpreted with caution.

Interventions for treatment of neonatal hyperglycemia in very low birth weight infants 
2 Studien, n=47
Evidence from randomized trials in hyperglycemic VLBW neonates is insufficient to determine the effects of treatment on death or major morbidities. It remains uncertain whether the hyperglycemia per se is a cause of adverse clinical outcomes or how the hyperglycemia should be treated.

Methotrexate for high-grade osteosarcoma in children and young adults   
Since no RCTs or CCTs in which only the use of MTX differed between the treatment groups were identified, no definitive conclusions can be made about the effects on antitumour efficacy, toxicities and quality of life of the addition of MTX to treatment of children and young adults with primary high-grade osteosarcoma.

Darm

Humanized antibody to the alpha4beta7 integrin for induction of remission in ulcerative colitis   
1 Studie
Data from one trial suggests that MLN-02 may be effective for induction of clinical response and remission in patients with moderately severe ulcerative colitis. Adverse events appear to be similar to placebo, although immunogenicity may be an issue. Further trials are needed to confirm the results of this study and to define the optimal dose and frequency of administration of MLN-02.

Infektionen

Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals  
1 RCT mit ungenügender statistischer Power
Presently there is no reliable evidence to support the use of any antiretroviral agent for HIV chemoprophylaxis.The value of chemoprophylaxis for HIV prevention cannot be assessed on the basis of the included trial.

Antiviral therapy for recurrent liver graft infection with hepatitis C virus  
11 Studien, n=389
Considering the lack of clinical benefit and the frequent adverse effects, there is currently no evidence to recommend antiviral treatment for recurrent liver graft infection with HCV.

Granulocyte transfusions for preventing infections in patients with neutropenia or neutrophil dysfunction 
10 Studien
The controlled trials that have been identified raise the possibility that prophylactic granulocyte transfusions at a dose of at least 1 x 1010 may reduce the risk of mortality from infection. Overall mortality was not affected. However, the majority of studies were performed decades ago, and standards of supportive care have advanced considerably.

Image-guided percutaneous procedure plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscess 
7 RCTs niederer Qualität, n=310
Therapeutic aspiration in addition to metronidazole to hasten clinical or radiologic resolution of uncomplicated amoebic liver abscesses cannot be supported or refuted by the present evidence. The trials lack methodological rigour and adequate sample size to conclude on the presence of effectiveness of adjunctive image-guided aspiration plus metronidazole versus metronidazole alone. Further randomised trials are necessary.

Interventions for preventing late postnatal mother-to-child transmission of HIV  
6 RCTs
Complete avoidance of breastfeeding is efficacious in preventing MTCT of HIV, but this intervention has significant associated morbidity (e.g., diarrheal morbidity if formula is prepared without clean water).  If breastfeeding is initiated, two interventions 1). exclusive breastfeeding during the first few months of life;  and 2)  chronic antiretroviral prophylaxis to the infant (nevirapine alone, or nevirapine with zidovudine) are efficacious in preventing transmission. 

Interventions for the prevention and treatment of herpes simplex virus in patients being treated for cancer
17 studien
There is evidence that aciclovir is efficacious in the prevention and treatment of herpes simplex virus infections. There is no evidence that valaciclovir is more efficacious than aciclovir, or that a high dose of valaciclovir is better than a low dose of valaciclovir. There is evidence that as a prophylaxis, placebo is more efficacious than prostaglandin E. However, in all included trials, risk of bias is unclear.
 
Iron supplementation for reducing morbidity and mortality in children with HIV 
Kein RCT
The current clinical practice of iron supplementation in HIV-infected children is based on weak evidence comprising observational studies and expert opinions.

Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease      
6 Studien, n=497
The results of this review have to be interpreted with caution because it was based on a limited number of participants included in studies whose methodological quality is questionable. Acetylcysteine and carbocysteine seem to have a limited efficacy and appear to be safe in children older than two years. These results should take into consideration the fact that acetylcysteine and carbocysteine are prescribed for self-limiting diseases (for example, acute cough, bronchitis). Regarding children younger than two years, given concerns about safety, these drugs should only be used for ARTIs in the context of an RCT.

Zähne

Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds   
Keine verwertbaren Studien
Randomized controlled studies comparing the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost are required.

Arthritis

Anakinra for rheumatoid arthritis  
5 Studien, n=2876Anakinra is a relatively safe and modestly efficacious biologic therapy for rheumatoid arthritis. Although head to head comparison trials have not been carried out, the amount of improvement is notably less when compared to studies using other biologic therapies.

Dietary interventions for rheumatoid arthritis 
15 Studien, n=837
The effects of dietary manipulation, including vegetarian, Mediterranean, elemental and elimination diets, on rheumatoid arthritis are still uncertain due to the included studies being small, single trials with moderate to high risk of bias. Higher drop-out rates and weight loss in the groups with dietary manipulation indicate that potential adverse effects should not be ignored.

Disease modifying anti-rheumatic drugs in people with cystic fibrosis-related arthritis    

Keine verwertbaren Studien
It is disappointing that no randomised controlled trials to rigorously evaluate DMARDs could be found.

Diverses 

The effect of social franchising on access to and quality of health services in low- and middle-income countries 
Keine verwertbaren Studien  
There is a need to develop rigorous studies to evaluate the effects of social franchising on access to and quality of health services in low- and middle-income countries.

Publication bias in clinical trials due to statistical significance or direction of trial results   
5 Studien
Trials with positive findings are published more often, and more quickly, than trials with negative findings.

Interventions for promoting information and communication technologies adoption in healthcare professionals 
10 Studien
There is very limited evidence on effective interventions promoting the adoption of ICTs by healthcare professionals. Small effects have been reported for interventions targeting the use of electronic databases and digital libraries. The effectiveness of interventions to promote ICT adoption in healthcare settings remains uncertain, and more well designed trials are needed.

Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura  
13 Studien mit unterschiedlichen Interventionen
This review also showed that in patients with typical or diarrhoea associated haemolytic uraemic syndrome, there are no interventions that are superior to supportive therapy which includes control of fluid and electrolyte imbalance, use of dialysis if required, control of hypertension and blood transfusion as required.

Interventions for increasing the proportion of health professionals practising in rural and other underserved areas  
Keine verwertbaren Studien
There are no studies in which bias and confounding are minimised to support any of the interventions that have been implemented to address the inequitable distribution of health care professionals.

Pharmacological interventions for preventing complications in idiopathic hypercalciuria   
5 Studien, n= 316
There is some evidence that in patients with idiopathic hypercalciuria and recurrent stones, the addition of thiazides to a normal or modified diet for short to long periods (five months to three years) reduced the number of stone recurrences and decreased the stone formation rate.

Interventions for pemphigus vulgaris and pemphigus foliaceus   
11 Studien, n= 404
There is inadequate information available at present to ascertain the optimal therapy for pemphigus vulgaris or pemphigus foliaceus. Further research is required.

Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment 
62 quasi-experimentelle Studien
This review supports the practice of treating kinship care as a viable out-of-home placement option for children removed from the home for maltreatment. However, this conclusion is tempered by the pronounced methodological and design weaknesses of the included studies.

Rehabilitation for older people in long-term care   
49 Studien, n=3611
Provision of physical rehabilitation interventions to long-term care residents is worthwhile and safe, reducing disability with few adverse events.
Most trials reported improvement in physical condition. However, there is insufficient evidence to make recommendations about the best intervention, improvement sustainability and cost-effectiveness.

Street lighting for preventing road traffic injuries 
14 Studien
The results from this systematic review suggests that street lighting may prevent road traffic crashes, injuries and fatalities. However, further well designed studies are needed to determine the effectiveness of street lighting in middle and low-income countries.

Alkylating agents for Waldenstrom's macroglobulinaemia  
1 Studie, n=92
Although alkylating agents have been used for decades they have never actually been tested in a proper randomised trial. This review demonstrated that there is currently no evidence to suggest that alkylating agents are effective in treating Waldenstrom's macroglobulinaemia.

Bone marrow harvest versus peripheral stem cell collection for haemopoietic stem cell donation in healthy donors
6 Studien, n= 807
The different short-term morbidities associated with each type of haemopoietic stem cell donation were clear, with bone marrow donors experiencing more pain and more restriction post-donation than peripheral blood donors. However, the studies were limited by their methodological quality, failure to provide long-term follow up (for which larger numbers of donors would be required) and a failure to apply consistent measures of quality of life in a way which allows more meaningful evaluation across studies.

Botulinum toxin for masseter hypertrophy   
Keine verwertbaren Studien
We were unable to identify any randomised controlled trials on the efficacy of intra-masseteric injections of botulinum toxin for people with bilateral benign masseter hypertrophy. The absence of high level evidence for the effectiveness of this intervention emphasises the need for well-designed, adequately powered, randomised controlled clinical trials (RCTs) and controlled clinical trials (CCTs).

Ausgewählte Updates mit veränderter klinischer Konsequenz, laut Cochrane:

Neurologie, Psychiatrie

Acupuncture for migraine prophylaxis 
22 Studien, N= 4419
In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of 'true' acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.

Acupuncture for tension-type headache
11 Studien, N= 2317
In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.

Immunosuppressant and immunomodulatory treatments for multifocal motor neuropathy     
1 RCT, n=28
In this update, we found the first randomised controlled trial of multifocal motor neuropathy. This study, which randomised 28 patients, showed that mycophenolate mofetil did not significantly improve strength or function or reduce the need for intravenous immunoglobulin. We summarised the results of retrospective and prospective case series in the discussion.

Intravenous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy 
7 Studien, N= 287
The evidence from randomised controlled trials shows that intravenous immunoglobulin improves disability for at least two to six weeks compared with placebo, with a number needed to treat of 3.00. During this period it has similar efficacy to plasma exchange and oral prednisolone. In one large trial, benefit of IVIg persisted for 24 and possibly 48 weeks.

Clozapine versus typical neuroleptic medication for schizophrenia  
42 Studien, N= 3950
Clozapine may be more effective in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse, than typical antipsychotic drugs - but data are weak and prone to bias. Participants were more satisfied with clozapine treatment than with typical neuroleptic treatment. The clinical effect of clozapine, however, is, at least in the short term, not reflected in measures of global functioning such as ability to leave the hospital and maintain an occupation. The short-term benefits of clozapine have to be weighed against the risk of adverse effects. Within the context of trials, the potentially dangerous white blood cell decline seems to be more frequent in children and adolescents and in the elderly than in young adults or people of middle-age.

Hypothermia for traumatic head injury  
22 Studien, N= 1409
Hypothermia may be effective in reducing death and unfavourable outcomes for traumatic head injured patients, but significant benefit was only found in low quality trials. Low quality trials have a tendency to overestimate the treatment effect. The high quality trials found some statistically non-significant benefit of hypothermia which could be due to the play of chance. Hypothermia may increase the risk of pneumonia. Due to uncertainties in its effects, hypothermia should only be given to patients taking part in a randomised controlled trial with good allocation concealment.

Treatment for amphetamine psychosis
1 RCT, N= 58
Limited evidence that antipsychotic medications effectively reduce symptoms of amphetamine psychosis.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers  
42 Studien
This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Kinder

Interventions for treating obesity in children 
64 Studien, N= 5230
While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Zahn

Interventions for replacing missing teeth: different times for loading dental implants 
22 Studien, N= 976
It is possible to successfully load dental implants immediately or early after their placement in selected patients, though not all clinicians may achieve optimal results. It is unclear whether it is beneficial to avoid occlusal contacts during the osseointegration phase. Trends suggest that immediately loaded implants fail more often than those conventionally loaded, but less commonly than those loaded early. If a clinician wishes to load the implants early, it might be wiser to load them immediately (within 1 week) rather than waiting for 1 or 2 months. A high degree of primary implant stability (high value of insertion torque) seems to be one of the prerequisites for a successful immediate/early loading procedure. More well designed RCTs are needed.

Darm

Azathioprine or 6-mercaptopurine for maintenance of remission in Crohn's disease 
8 Studien
Azathioprine and 6-mercaptopurine are more effective than placebo for maintenance of remission in Crohn's disease. Higher response rates were obtained with azathioprine than 6-mercaptopurine. However, the one study evaluating 6-mercaptopurine used a relatively low dose of the drug.

Budesonide for maintenance of remission in Crohn's disease    
11 Studien
Budesonide is not more effective than placebo or weaning prednisolone for maintenance of remission in Crohn's disease. Some modest benefits are noted in patients receiving budesonide compared with placebo in terms of lower CDAI scores and longer time to relapse of disease. However, these benefits are offset by higher treatment-related adverse event rates and more frequent adrenocorticoid suppression in patients receiving budesonide. Therefore, budesonide is not recommended for maintenance of remission in Crohn's disease.

Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease
6 Studien
Omega 3 fatty acids are safe but probably ineffective for maintenance of remission in CD. The existing data do not support routine maintenance treatment of Crohn's disease with omega 3 fatty acids.

Atmung

Inhaled corticosteroids for cystic fibrosis 
13 Studien, N= 506
Evidence from these trials is insufficient to establish whether ICS are beneficial in CF, but withdrawal in those already taking them has been shown to be safe. There is some evidence they may cause harm in terms of growth. It has not been established whether long-term use is beneficial in reducing lung inflammation, which should improve survival, but it is unlikely this will be proven conclusively in a randomised controlled trial.

Inhaled steroids for bronchiectasis 
6 Studien, N= 303
The present review indicates that there is insufficient evidence to recommend the routine use of inhaled steroids in adults with stable state bronchiectasis. While a therapeutic trial may be justified in adults with difficult to control symptoms and in certain subgroups, this has to be balanced with adverse events especially if high doses are used. No recommendation can be made for the use of ICS in adults during an acute exacerbation or in children (for any state) as there were no studies.

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease  
11 Studien, N= 1081
Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment and shortens hospital stay. It increases the rate of improvement in lung function and dyspnoea and the improvement continues during treatment, but there is a significantly increase in the risk of an adverse drug event occurring. The optimal dose and length of treatment regime needs to be better defined.

Frauen

Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus
5 Studien, 6145 Babies
The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established. The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95% confidence interval 43 to 87). Given the beneficial effects of magnesium sulphate on substantial gross motor function in early childhood, outcomes later in childhood should be evaluated to determine the presence or absence of later potentially important neurological effects, particularly on motor or cognitive function.

Krebs

Neoadjuvant and adjuvant therapy for surgical resection of hepatocellular carcinoma
12 Studien, N= 843
There is no clear evidence for efficacy of any of the adjuvant and neo-adjuvant protocols reviewed, but there is some evidence to suggest that adjuvant therapy may be beneficial offering prolonged disease-free survival. In order to detect a realistic treatment advantage, larger trials with lower risk of systematic error will have to be conducted.

Nutrition support for bone marrow transplant patients
In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite.

Single dose oral naproxen and naproxen sodium for acute postoperative pain in adults 
10 Studien, N= 996
Doses equivalent to 500 mg and 400 mg naproxen administered orally provided effective analgesia to adults with moderate to severe acute postoperative pain. About half of participants treated with these doses experienced clinically useful levels of pain relief, compared to 15% with placebo, and half required additional medication within nine hours, compared to two hours with placebo. Associated adverse events did not differ from placebo.

Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis  
5 Studien, n=719
Adeno-/tonsillectomy is effective in reducing the number of episodes of sore throat and days with sore throats in children, the gain being more marked in those most severely affected. The size of the effect is modest, but there may be a benefit to knowing the precise timing of one episode of pain lasting several days - it occurs immediately after surgery as a direct consequence of it.
It is clear that some children get better without any surgery, and that whilst removing the tonsils will always prevent 'tonsillitis', the impact of the procedure on 'sore throats' due to pharyngitis is much less predictable.

Compression for venous leg ulcers  
Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.

Early discharge hospital at home
26 Studien, N= 3967
Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Ear drops for the removal of ear wax  
9 Studien, n=679
Trials have been heterogeneous and generally of low or moderate quality, making it difficult to offer any definitive recommendations on the effectiveness of cerumenolytics for the removal of symptomatic ear wax. Using drops of any sort appears to be better than no treatment, but it is uncertain if one type of drop is any better than another. Future trials should be of high methodological quality, have large sample sizes, and compare both oil-based and water-based solvents with placebo, no treatment or both.

Relapse prevention interventions for smoking cessation 
54 Studien
At the moment there is insufficient evidence to support the use of any specific behavioural intervention for helping smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focusing on identifying and resolving tempting situations, as most studies were concerned with these. There is little research available regarding other behavioural approaches.
Extended treatment with varenicline may prevent relapse. Extended treatment with bupropion is unlikely to have a clinically important effect. Studies of extended treatment with nicotine replacement are needed.

[nach oben]

Cognition

Ginkgo biloba for cognitive impairment and dementia  
36 Studien
Ginkgo biloba appears to be safe in use with no excess side effects compared with placebo. Many of the early trials used unsatisfactory methods, were small, and publication bias cannot be excluded. The evidence that Ginkgo biloba has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unreliable.

Hormone replacement therapy to maintain cognitive function in women with dementia 
7 Studien, N= 351
There is no evidence of a positive effect that estrogen replacement therapy can maintain cognitive function for a longer period of time (> five months) in women with Alzheimer's disease.