Die 5 Minuten Evidenz - Cochrane Ausgabe 2/2009

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Ausgabe 2/2009 der Cochrane Library

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Alcohol and drug screening of occupational drivers for preventing injury
2 Nicht RCTs
There is insufficient evidence to advise for or against the use of drug and alcohol testing of occupational drivers for preventing injuries as a sole, effective, long-term solution in the context of workplace culture, peer interaction and other local factors.

Effects of changes in the pre-licensure education of health workers on health-worker supply
2 Studien mit moderate to high risk of bias
The evidence to estimate the likely effects of interventions in pre-licensure education to increase health-worker supply is generally insufficient or unavailable, particularly in LMICs.

Workplace interventions for preventing work disability
6 RCTs (n=749)
As a result of the few available studies, no convincing conclusions can be formulated about the effectiveness of workplace interventions on work-related outcomes and health outcomes regardless of the type of work disability.

Written information about individual medicines for consumers
25 RCTs (n=4788)
No studies showed an adverse effect of medicines information.
The combined evidence was not strong enough to say whether written medicines information is effective in changing knowledge, attitudes and behaviours related to medicine taking. There is some evidence that written information can improve knowledge. The trials were generally of poor quality.

Gefäße

Angioplasty versus stenting for superficial femoral artery lesions
8 Studien (n=968)
There is limited benefit to stenting lesions of the superficial femoral artery in addition to angioplasty, however this cannot be recommended routinely based on the results of this analysis.

Ginkgo biloba for intermittent claudication
14 Studien (n=739)
Overall, there is no evidence that Ginkgo biloba has a clinically significant benefit for patients with peripheral arterial disease.

Repositioning for treating pressure ulcers
Keine RCTs
Despite the widespread use of repositioning as a component of the management plan for individuals with existing pressure ulcers, no randomised trials exist that assess the effects of repositioning patients on the healing rates of pressure ulcers.

Herz Kreislauf, CVD

HMG CoA reductase inhibitors (statins) for kidney transplant recipients
16 Studien (n=3229)
Statins significantly reduced hyperlipidaemia and tended to reduce cardiovascular events in kidney transplant recipients, but no effect has yet been demonstrated for mortality outcomes. Most of the data was derived from one large long-term study.

HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis
Main 26 Studien (n=25.017)
Statins significantly reduced the risk of all-cause and cardiovascular mortality in CKD patients who are not receiving renal replacement therapy. They do not impact on the decline in renal function as measured by creatinine clearance, but may reduce protein excretion in urine.

Mailuoning for acute ischaemic stroke
15 Studien (n=1280), reduzierte Qualität
We found no convincing evidence, from trials of sufficient methodological quality, to support the routine use of mailuoning to promote recovery after stroke.

Music for stress and anxiety reduction in coronary heart disease patients
23 Studien (n=1461)
Music listening may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, and pain in persons with CHD. However, the quality of the evidence is not strong and the clinical significance unclear.

Infektion

Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding
9 Studien
The pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings.

Antibiotics for treating osteomyelitis in people with sickle cell disease
Keine RCTs
We were unable to identify any relevant trials on the efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from osteomyelits.

Antiviral treatment for preventing postherpetic neuralgia
6 Studien (n=121)
Oral acyclovir did not reduce the incidence of PHN significantly. There is insufficient evidence from randomised controlled trials to determine whether other antiviral treatments prevent PHN.

Immunoglobulins for preventing hepatitis A
13 Studien (n=567.476)
Immunoglobulins seem to be effective for pre-exposure and post-exposure prophylaxis of hepatitis A. However, caution is warranted for the positive findings due to the limited number of trials, year of conductance, and risk of bias.

Interventions for American cutaneous and mucocutaneous leishmaniasis
38 Studien (n=2728)
Most trials have been designed and reported so poorly that they are inconclusive.

Vaccines for preventing anthrax
Ein Cluster-RCT (n=157.259 participants) und 4 RCTs (n=1917)
One cluster-RCT provides limited evidence that a live-attenuated vaccine is effective in preventing cutaneous anthrax. Vaccines based on anthrax antigens are immunogenic in most vaccinees with few adverse events or reactions.

Antiamoebic drugs for treating amoebic colitis
37 Studien (n=4487), aber nur eine mit ausreichender Methodik
Tinidazole is more effective in reducing clinical failure compared with metronidazole and has fewer associated adverse events. Combination drug therapy is more effective in reducing parasitological failure compared with metronidazole alone. However, these results are based on trials with poor methodological quality so there is uncertainty in these conclusions.

Kinder

Alternatives to inpatient mental health care for children and young people
7 Studien (n=799 )
The quality of the evidence base currently provides very little guidance for the development of services. If randomised controlled trials are not feasible then consideration should be given to alternative study designs, such as prospective systems of audit conducted across several centres, as this has the potential to improve the current level of evidence. These studies should include baseline measurement at admission along with demographic data, and outcomes measured using a few standardised robust instruments.

Antistaphylococcal immunoglobulins to prevent staphylococcal infection in very low birth weight infants
3 Studien (n=2701)
Antistaphylococcal immunoglobulins (INH A-21 and Altastaph) are not recommended for prevention of staphylococcal infections in preterm or VLBW neonates. Further research to investigate the efficacy of other products such as Pagibaximab is needed.

Honey and lozenges for children with non-specific cough
Keine geigneten Studien
Clinically, this review was unable to provide any justifiable recommendation for or against honey and/or lozenges due to the lack of evidence.

Influenza vaccination in children being treated with chemotherapy for cancer
1 RCT, 8 CCTs ( n=708)
None of the included studies reported on clinical outcome. Paediatric oncology patients receiving chemotherapy are able to generate an immune response to the influenza vaccine, but it remains unclear whether this immune response protects them from influenza infection or its complications.

Nutritional support for critically ill children
Eine Studie bei 77 Kindern mit reduzierter Qualität
Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.

Animal derived surfactant extract for treatment of respiratory distress syndrome
13 RCTs
Infants with established respiratory distress syndrome who receive animal derived surfactant extract treatment have a decreased risk of pneumothorax, a decreased risk of pulmonary interstitial emphysema, a decreased risk of mortality, and a decreased risk of bronchopulmonary dysplasia or death.

Education of children and adolescents for the prevention of dog bite injuries
2 Studien moderater Qualität
There is no direct evidence that educational programmes can reduce dog bite rates in children and adolescents.

Detoxification treatments for opiate dependent adolescents
1 Studie (n=36)
It is difficult to draft conclusions on the basis of only one trial with few participants. Furthermore, the only study included did not consider the efficacy of methadone that is still the most frequent drug utilized for the treatment of opioid withdrawal. One possible reason for the lack of evidence could be the difficulty in conducting trials with young people for to practical and ethical reasons.

Augen

Beta radiation for glaucoma surgery
4 Studien (n=55)
Trabeculectomy with beta irradiation has a lower risk of surgical failure compared to trabeculectomy alone. A trial of beta irradiation versus anti-metabolite is warranted.

Botulinum toxin for the treatment of strabismus
4 RCTs
The majority of published literature on the use of botulinum toxin in the treatment of strabismus consists of retrospective studies, cohort studies or case reviews. Although these provide useful descriptive information, clarification is required as to the effective use of botulinum toxin as an independent treatment modality.

Interventions for improving adherence to ocular hypotensive therapy
8 Studien mäßiger Qualität
Interventions involving simplified dosing regimes, reminder devices, education and individualised care planning, did show improvements in adherence rates. However, due to inadequate methodological quality and heterogeneity of study design we are unable to advocate any particular interventions at this time.

Interventions for prevention of giant retinal tear in the fellow eye
Keine relevanten Studien
No strong evidence in the literature was found to support or refute prophylactic 360-degree treatments to prevent a giant retinal tear or a retinal detachment in the fellow eye of patients with unilateral giant retinal tears.

Photorefractive keratectomy (PRK) versus laser assisted in situ keratomileusis (LASIK) for hyperopia correction
Keine relevanten Studien
No robust, reliable conclusions could be reached, but the non-randomised trials reviewed appear to be in agreement that hyperopic-PRK and hyperopic-LASIK are of comparable efficacy.

Routine preoperative medical testing for cataract surgery
3 Studien (21.531 cataract surgeries with 707 total surgery-associated medical adverse events).
This review has shown that routine pre-operative testing does not increase the safety of cataract surgery.

Submacular surgery for choroidal neovascularisation secondary to age-related macular degeneration
2 Studien (n=790)
There is no benefit with submacular surgery in most people with subfoveal choroidal neovascularisation due to AMD in terms of prevention of visual loss. Furthermore, the risk of developing cataract and retinal detachment increases after surgery.

Krebs

Homeopathic medicines for adverse effects of cancer treatments
8 Studien (n=664).
This review found preliminary data in support of the efficacy of topical calendula for prophylaxis of acute dermatitis during radiotherapy and Traumeel S mouthwash in the treatment of chemotherapy-induced stomatitis.

Liver resection versus other treatments for neuroendocrine tumours in patients with resectable liver metastases
Keine RCTs gefunden

Rituximab as maintenance therapy for patients with follicular lymphoma
5 Studien (n=1056)
Patients treated with rituximab as maintenance therapy had a significantly better overall survival compared to observation alone (HR 0.53, 95% CI 0.38 to 0.73).

Second-line chemotherapy in advanced and metastatic CRC
Main results 7 RCTs
Second-line chemotherapy is effective in prolonging time to progression and survival in patients with advanced colorectal cancer. Further RCTs are needed to assess the optimal chemotherapy regimen.

Cognition

Cannabinoids for the treatment of dementia
Eine Studie
The data in the study report were presented in such a way that they could not be extracted for further analysis and there was insufficient quantitative data to validate the results.

Enteral tube feeding for older people with advanced dementia
Keine RCTs, 7 Beobachtungsstudien
Despite the very large number of patients receiving this intervention, there is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.

Huperzine A for vascular dementia
1 Studie (n=14)
There is no [convincing] evidence that Huperzine A is of value in vascular dementia based on one small trial. It deserves further research.

Atmung

Chemical pleurodesis versus surgical intervention for persistent and recurrent pneumothoraces in cystic fibrosis
Keine Studie
This systematic review identifies the need for a multicentre randomised controlled trial assessing both efficacy and possible adverse effects of the use of chemical pleurodesis versus surgical interventions for the treatment of persistent and recurrent pneumothoraces in people with cystic fibrosis.

Combination formoterol and budesonide as maintenance and reliever therapy versus inhaled steroid maintenance for chronic asthma in adults and children
5 Studien (n= 5378)
Single inhaler therapy can reduce the risk of asthma exacerbations needing oral corticosteroids in comparison with fixed dose maintenance inhaled corticosteroids.

Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation
7 Studien (n= 1170)
There is not evidence to make conclusions on whether recruitment manoeuvres reduce mortality or length of ventilation in patients with ALI or ARDS.

Regular treatment with formoterol and inhaled steroids for chronic asthma: serious adverse events
The 21 Studien (n<10.000)
Clinical decisions and information for patients regarding regular use of formoterol have to take into account the balance between known symptomatic benefits of formoterol and the degree of uncertainty and concern associated with its potential harmful effects.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea
17 Studien (n=1070)
There is some evidence that a supportive intervention which encourages people to continue to use their CPAP machines leads to greater levels of CPAP machine usage than control, although the variation across the studies introduces some uncertainty over how consistent this effect is. We could not find evidence that a short-term educational intervention led to improvements in usage.

Neurologie/Psychiatrie

Chlorpromazine dose for people with schizophrenia
4 Studien (n=1012)
The average dose of chlorpromazine given to people with schizophrenia has declined across time, but this has come about by long - and sometimes hard - experience rather than from direction from high-grade trial-based evidence. This progression towards gentler levels of dosing has taken six decades. We hope that, for modern compounds, data from relevant high-grade evaluative studies will be much more swiftly available to guide informed practice.

Escitalopram versus other antidepressive agents for depression 
22 Studien
Some statistically significant differences favouring escitalopram over other antidepressive agents for the acute phase treatment of major depression were found, in terms of efficacy (citalopram and fluoxetine) and acceptability (duloxetine). There is insufficient evidence to detect a difference between escitalopram and other antidepressants in early response to treatment (after two weeks of treatment). Cost-effectiveness information is also needed in the field of antidepressant trials. Furthermore, as with most standard systematic reviews, the findings rely on evidence from direct comparisons. The potential for overestimation of treatment effect due to sponsorship bias should also be borne in mind.

Sertraline versus other antidepressive agents for depression
59 Studien, meist niederer Qualität
This systematic review and meta-analysis highlighted a trend in favour of sertraline over other antidepressive agents both in terms of efficacy and acceptability, using 95% confidence intervals and a conservative approach, with a random effects analysis. However, the included studies did not report on all the outcomes that were pre-specified in the protocol of this review. Outcomes of clear relevance to patients and clinicians were not reported in any of the included studies.

Interventions for improving the psychosocial well-being of children affected by HIV and AIDS.
Keine Studien
Current practice is based on anecdotal knowledge, descriptive studies and situational analyses. Such studies do not provide a strong evidence base for the effectiveness of these interventions.

Interventions for apathy after traumatic brain injury
1 Studie (n=21)
No evidence was provided to support the use of CES treatment for inertia, a component of apathy.

Pimozide for tics in Tourette's syndrome
6 RCTs (n=162)
Pimozide is an effective treatment for tics in Tourette Syndrome, though the number of trials comparing its effect to placebo and other drugs is limited.

Risperidone for attention-deficit hyperactivity disorder in people with intellectual disabilities
11 Studien
There is no evidence from RCTs that risperidone is effective for the treatment of ADHD in people with ID.

Sertindole versus other atypical antipsychotics for schizophrenia
2 RCTs mäßiger Qualität (=508) Sertindole may induce fewer movement disorders, but more cardiac effects, weight change and male sexual dysfunction than risperidone.

Sulpiride versus placebo for schizophrenia
Zwei Studien (n=113). Sulpiride may be an effective antipsychotic drug but evidence of its superiority over placebo from randomised trials is very limited. Practice will have to use evidence from sources other than trials until better evidence is generated.

Twenty-four hour care for schizophrenia
Eine Studie (n=22) mäßiger Qualität From the single, small and ill-reported, included study, the hostel ward type of facility appeared cheaper and positively effective. Currently, the value of this way of supporting people - which could be considerable - is unclear. Trials are needed. Any 24 hour care 'ward-in-a-house' is likely to be oversubscribed.

Chirurgie

Conservative interventions for treating middle third clavicle fractures in adolescents and adults
Drei Studien (n=354) mäßiger Qualität
There is insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for acute middle third clavicle fractures in adolescents and adults. Further research is warranted.

Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy
15 RCTs (n=690)
Low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established.

Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma
Keine Studien gefunden
No reliable conclusions could be reached regarding which method of treatment (SE or MMS) resulted in a lower recurrence or complication rate for periocular BCC. No studies were found comparing the cost of either method directly.

Surgery versus radical endotherapies for early cancer and high grade dysplasia in Barrett's oesophagus
Keine geeigneten RCTs
This Cochrane review has indicated that there are no randomised control trials to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites; standardising histopathology in all centres; assessing which patients are fit or unfit for surgery; and making sure there are relevant outcomes for the study i.e. no progression of high grade dysplasia or long term survival i.e. over five years.

Sturz, Fraktur

Interventions for preventing falls in older people living in the community
111 Studien (n=55.303)
Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Zahn

Dental fillings for the treatment of caries in the primary dentition
3 Studien ( n=81)
It was disappointing that only three trials that compared three different types of materials were suitable for inclusion into this review. There were no significant differences found in all three trials for all of the outcomes assessed. Well designed, randomised controlled trials comparing the different types of filling materials for similar outcomes are urgently needed in dentistry. There was insufficient evidence from the three included trials to make any recommendations about which filling material to use.

Extraction of primary (baby) teeth for unerupted palatally displaced permanent canine teeth in children
31 Studien wurden als Volltext examiniert, 19 were non-English and required translation. Die Daten von zwei RCTs wurden nicht adäquat präsentiert.
There is currently no evidence to support the extraction of the deciduous maxillary canine to facilitate the eruption of the palatally ectopic maxillary permanent canine. Two randomised controlled trials were identified but unfortunately, due to deficiencies in reporting, they cannot be included in the review at the present time.

Root coverage procedures for the treatment of localised recession-type defects
24 RCTs, aber nur eine Studie mit niedrigem Risiko für Bias
Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for the treatment of localised recession-type defects. In cases where both root coverage and gain in the keratinized tissue are expected, the use of subepithelial connective tissue grafts seems to be more adequate.
Randomised controlled clinical trials are necessary to identify possible factors associated with the prognosis of each PPS procedure. The potential impact of bias on these outcomes is unclear.

Frauen

Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care
12 Studien (n=7792)
The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of caesarean section; however, the confidence interval crossed unity and was compatible with no effect (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.79 to 1.01).
In Prevention trials, early augmentation was associated with a modest reduction in the number of caesarean births (RR 0.88; 95% CI 0.77 to 0.99).

Effect of administration of antihelminthics for soil transmitted helminths during pregnancy
Drei Studien (n=1329)
The evidence to date is insufficient to recommend use of antihelminthics for pregnant women after the first trimester of pregnancy.

Effects of restricted caffeine intake by mother on fetal, neonatal and pregnancy outcome
Eine Studie
Caffeinated instant coffee (568 women) was compared with decaffeinated instant coffee (629 women) and it was found that reducing the caffeine intake of regular coffee drinkers (3+ cups/day) during the second and third trimester by an average of 182 mg/day did not affect birthweight or length of gestation.

Herbal preparations for uterine fibroids
Zwei RCTs (n =150)
Current evidence does not support or refute the use of herbal preparations for treatment of uterine fibroids due to insufficient studies of large sample and high quality.

Interventions for psychosexual dysfunction in women treated for gynaecological malignancy
Fünf Studien (n=413)
One trial suggested a short-term benefit for the use of vaginal Dienoestrol in women after pelvic radiotherapy (NNT = 4). Another trial suggested a short-term benefit for one regime of low dose-rate brachytherapy over another but this modality is not in widespread use. Studies of a Clinical Nurse Specialist intervention, Psychoeducational Group Therapy and a Couple-Coping intervention, did not show any significant benefit. All the studies were of poor methodological quality.

Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome
The pooled odds ratio (OR) for live birth rate (3 RCTs) was 0.77 ( 95% CI 0.27 to 2.18) and for clinical pregnancy rate (5 RCTS) was 0.71 (95% CI 0.39 to 1.28). The risk of OHSS in women with PCOS and undergoing IVF or ICSI cycles was reduced with metformin (pooled OR 0.27, 95% CI 0.16 to 0.47).
This review found no evidence that metformin treatment before or during ART cycles improves live birth or pregnancy rates. The risk of OHSS in women with PCOS and undergoing IVF or ICSI cycles was reduced with metformin.

Maternal positions and mobility during first stage labour
21 Studien (n=3706 )
There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.

Music during caesarean section under regional anaesthesia for improving maternal and infant outcomes
Eine Studie (n= 76)
The findings indicate that music during planned caesarean section under regional anaesthesia may improve pulse rate and birth satisfaction score. However, the magnitude of these benefits is small and the methodological quality of the one included trial is questionable. Therefore, the clinical significance of music is unclear.

Outpatient versus inpatient induction of labour for improving birth outcomes
Drei Studein (n=612)
The data available to evaluate the efficacy or potential hazards of outpatient induction are limited. It is, therefore, not yet possible to determine whether induction of labour is effective and safe in outpatient settings.

Pain control in first trimester surgical abortion
Vierzig Studien (n=5131) participants. Due to heterogeneity we divided studies into 7 groups:
Conscious sedation, GA and some non-pharmacological interventions decreased procedural and postoperative pain, while being safe and satisfactory to patients. Data on the widely used PCB is inadequate to support its use, and it needs to be further studied to determine any benefit.

Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy
Vier Studien (n=715)
The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women.

Schmerz

Intravenous or intramuscular parecoxib for acute postoperative pain in adults
Sieben Studien(n=1446)
A single dose of parecoxib 20 mg or 40 mg provided effective analgesia for 50 to 60% of those treated compared to about 15% with placebo, and was well tolerated. Duration of analgesia was longer, and significantly fewer participants required rescue medication over 24 hours with the higher dose.

Psychological therapies for the management of chronic pain (excluding headache) in adults
40 Studien (n=4781)
CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months.

Single dose oral etoricoxib for acute postoperative pain in adults
Fünf Studien (n=880)
Single dose oral etoricoxib produces high levels of good quality pain relief after surgery. The 120 mg dose is as effective as, or better than, other commonly used analgesics.

Transcutaneous electrical nerve stimulation for acute pain
Zwölf Studien (n=919)
Due to insufficient extractable data in the studies included in this review, we are unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain in adults.

Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour
19 Studien (n=1671)
There is only limited evidence that TENS reduces pain in labour and it does not seem to have any impact (either positive or negative) on other outcomes for mothers or babies. The use of TENS at home in early labour has not been evaluated. TENS is widely available in hospital settings and women should have the choice of using it in labour.

Sucht

Maintenance treatments for opiate dependent adolescent
Zwei Studien (n=187)

Magen-Darm

Polymer-based oral rehydration solution for treating acute watery diarrhoea
34 Studien (n=4214)

Red cell transfusion for the management of upper gastrointestinal haemorrhage
Drei Studien (n=93), ein RCT (n=860) muss noch beendet werden.
There were more deaths and more rebleeding in the transfusion arms of the combined studies, but the small numbers of participants and large volume of missing data limit the significance of the findings. The studies in this review do not provide useful data regarding outcomes following red blood cell transfusion for acute upper gastrointestinal haemorrhage. They appear to exclude large survival benefit. Large, well-concealed randomised controlled trials of sufficient power are urgently needed.

Thalidomide and thalidomide analogues for induction of remission in Crohn's disease
Keine geeigneten RCTs
The results of one well designed study using lenalidomide did not show any statistically significant benefit over placebo. The use of thalidomide or lenalidomide for induction of remission in Crohn's disease is not recommended until data from a definitive study are available.

Thalidomide and thalidomide analogues for maintenance of remission in Crohn's disease
Keine relevanten Studien gefunden
There is no evidence to support or refute the use of thalidomide or its analogue, lenalidomide, as maintenance therapy for patients with Crohn's disease. Given the teratogenic nature of thalidomide its use for maintenance therapy is difficult to justify. Well designed clinical trials are needed to evaluate the efficacy and safety of lenalidomide in Crohn's disease and its use is not recommended until these data are available.

Diverses

Carnitine supplementation for inborn errors of metabolism
Keine geeigneten RCTs
In the absence of any high level evidence, clinicians should base their decisions on clinical experience and in conjunction with preferences of the individual where appropriate. This does not mean that carnitine is ineffective or should not be used in any inborn error of metabolism. However, given the lack of evidence both on the effectiveness and safety of carnitine and on the necessary dose and frequency to be prescribed, the current prescribing practice should continue to be observed and monitored with care until further evidence is available.

Haloperidol for the treatment of nausea and vomiting in palliative care patients
We did not identify any RCTs exploring the effectiveness of haloperidol for nausea and vomiting in palliative care patients.

Pharmacological treatment for Kleine-Levin Syndrome
Keine relevanten Studien gefunden
Therapeutic trials of pharmacological treatment for Kleine-Levin Syndrome, with a double-blind, placebo-controlled design are needed.

Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults
Acht Berichte über RCTs, ohne klare Patientenangabe (mehrfach erfasst?)
In spite of methodological problems, it would appear that some people benefit from implants which provide continuous nerve stimulation. More research is needed on the best way to improve patient selection, carry out the implant, and to find why so many fail. The effectiveness of implants should be tested against other interventions, particularly in people with an overactive bladder.

Topical treatments for chronic plaque psoriasis
131 RCTs (n=21.448)
Corticosteroids perform as well as vitamin D analogues and are associated with a lower incidence of local adverse events. Further research is required to inform long-term maintenance treatment.

Ausgewählte Updates mit veränderter klinischer Konsequenz:

Kinder

Adenotonsillectomy for obstructive sleep apnoea in children
Eine Studie There is an absence of randomised controlled trials investigating the efficacy of treatment of confirmed obstructive sleep apnoea with adenotonsillectomy in children. Research is required before recommendations for the treatment of obstructive sleep apnoea in children can be formulated. The quality of research in this area could be improved with the use of sleep studies at baseline to determine the extent of severity of sleep apnoea in children who are recruited to studies in this area. Long-term follow up is also required in order to explore the effect of adenotonsillectomy on paediatric sleep apnoea.

Interventions for educating children who are at risk of asthma-related emergency department attendance
38 Studien(n=7843)
Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

Pneumococcal vaccines for children and adults with bronchiectasis
Eine Studie (n=167)
Current but limited evidence support the use of 23-valent pneumococcal vaccine as routine management in adults with bronchiectasis. Circumstantial evidence also support the use of routine 23-valent pneumococcal vaccination in children with bronchiectasis. Further randomised controlled trials examining the efficacy of this intervention using various vaccine types in different age groups are needed. There is no data on the efficacy of pneumococcal vaccine on pulmonary decline. With the lack of evidence in how often the vaccine should be given, it is recommended that health providers adhere to national guidelines.

Sucht

Alpha2-adrenergic agonists for the management of opioid withdrawal
24 Studien (n=1631)
Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. No significant difference in efficacy was detected for treatment regimes based on clonidine or lofexidine, and those based on reducing doses of methadone over a period of around 10 days but methadone is associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.

Biomedical risk assessment as an aid for smoking cessation
11 Studien
There is little evidence about the effects of most types of biomedical tests for risk assessment. Spirometry combined with an interpretation of the results in terms of 'lung age' had a significant effect in a single good quality trial. Mixed quality evidence does not support the hypothesis that other types of biomedical risk assessment increase smoking cessation in comparison to standard treatment. Only two pairs of studies were similar enough in term of recruitment, setting, and intervention to allow meta-analysis.

Treatment for amphetamine withdrawal
4 Studien (n=125)
No medication is effective for treatment of amphetamine withdrawal. Amineptine showed reduction in discontinuation rates and improvement in clinical presentation compared to placebo, but had no effect on reducing withdrawal symptoms or craving. In spite of these limited benefits, amineptine is not available for use due to concerns over abuse liability when using the drug. The benefits of mirtazapine as a withdrawal agent are less clear based on findings from two randomised controlled trials: one report showed improvements in amphetamine withdrawal symptoms over placebo; a second report showed no differences in withdrawal symptoms compared to placebo. Further potential treatment studies should examine medications that increase central nervous system activity involving dopamine, norepinephrine and/or serotonin neurotransmitters, including mirtazapine.

Herz Kreislauf

HMG CoA reductase inhibitors (statins) for dialysis patients
14 Studien (n=2086)
Statins decreased cholesterol levels in dialysis patients similar to that of the general population. With the exception of one study, studies were of short duration and therefore the efficacy of statins in decreasing the mortality rate is still unclear. Statins appear to be safe in this high-risk population. Ongoing studies should provide more insight about the efficacy of statins in reducing mortality rates in dialysis patients.

Neurologie/Psychiatrie

Hypothermia for traumatic head injury
23 Studien (n=1614)
There is no evidence that hypothermia is beneficial in the treatment of head injury. 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 no decrease in the likelihood of death with hypothermia, but this finding was not statistically significant and could be due to the play of chance. Hypothermia should not be used except in the context of a high quality randomised controlled trial with good allocation concealment.

Rivastigmine for Alzheimer's disease
Neun Studien (n=4775)
Rivastigmine appears to be beneficial for people with mild to moderate Alzheimer's disease. In comparisons with placebo, improvements were seen in the rate of decline of cognitive function, activities of daily living, and severity of dementia with daily doses of 6 to 12 mg. Adverse events were consistent with the cholinergic actions of the drug. A transdermal patch has been tested in one trial, and there is evidence that the lower dose smaller patch is associated with fewer side effects than the capsules or the higher dose larger patch and has comparable efficacy to both. This review has not examined economic data.

Statins for the prevention of dementia
Zwei Studien (n=26.340)
There is good evidence from RCTs that statins given in late life to individuals at risk of vascular disease have no effect in preventing AD or dementia. Biologically it seems feasible that statins could prevent dementia due to their role in cholesterol reduction and initial evidence from observational studies was very promising. Indication bias may have been a factor in these studies however and the evidence from subsequent RCTs has been negative.

Infektion

Male circumcision for prevention of heterosexual acquisition of HIV in men
3 große RCTs mit über 10.000 Teilnehmern
There is strong evidence that medical male circumcision reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months. Incidence of adverse events is very low, indicating that male circumcision, when conducted under these conditions, is a safe procedure. Inclusion of male circumcision into current HIV prevention measures guidelines is warranted, with further research required to assess the feasibility, desirability, and cost-effectiveness of implementing the procedure within local contexts.

Nebulised hypertonic saline for cystic fibrosis
12 Studien (n=442)
Treatment with 7% HS for 48 weeks showed a small improvement in FEV1 at four weeks; however, this was not sustained at 48 weeks (primary outcome measure of the only long-term trial). Unlike RhDNAse, HS can't, in the long term, be said to improve lung function. However, it did improve quality of life and reduce pulmonary exacerbations. Delivered following a bronchodilator, HS appears inexpensive and safe with no increased infection risk.
We believe there is sufficient evidence to recommend using HS in CF; qualifying this we highlight that the only long-term trial failed to demonstrate a significant difference in its primary outcome (lung function) with improvements only in secondary outcomes.

Diverses

Continuing education meetings and workshops: effects on professional practice and health care outcomes
81 Studien (n über 11.000)
Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

Intercessory prayer for the alleviation of ill health
10 Studien (n=7646)
These findings are equivocal and, although some of the results of individual studies suggest a positive effect of intercessory prayer,the majority do not and the evidence does not support a recommendation either in favour or against the use of intercessory prayer. We are not convinced that further trials of this intervention should be undertaken and would prefer to see any resources available for such a trial used to investigate other questions in health care.

Protein and energy supplementation in elderly people at risk from malnutrition
66 Studien (n= 10.187)
Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Serenoa repens for benign prostatic hyperplasia
30 Studien (n=5222)
Serenoa repens was not more effective than placebo for treatment of urinary symptoms consistent with BPH.

Single dose oral diclofenac for acute postoperative pain in adults
15 Studien (n= 1512)
Oral diclofenac is an effective single-dose treatment for moderate to severe postoperative pain. Significantly more participants experienced at least 50% pain relief over 4 to 6 hours with diclofenac potassium than with diclofenac sodium. There was no significant difference between diclofenac and placebo in he incidence of adverse events.

Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting
40 Studien (n= 4858)
P6 acupoint stimulation prevented postoperative nausea and vomiting (PONV). There was no reliable evidence for differences in risks of postoperative nausea or vomiting after P6 acupoint stimulation compared to antiemetic drugs.

Surgery for obesity
26 Studien
Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.