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Die 5 Minuten Evidenz - Cochrane Ausgabe 4/2009

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Ausgabe 4/2009 der Cochrane Library

Bitte wählen Sie Ihr Thema aus:
Herz, Kreislauf, CVD	Infektion	Kinder
Augen	Krebs	Exercise
Atmung	Urologie	Neurologie/Psychiatrie
Chirurgie	Zahn	Frauen
Schmerz	Diverses

Ausgewählte Updates mit veränderter klinischer Konsequenz:

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Herz, Kreislauf, CVD

Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery

31 Studien (n= 4578)
Our study provides encouraging evidence that a-2 adrenergic agonists may reduce cardiac risk, especially during vascular surgery. Nonetheless, these data remain insufficient to make firm conclusions about their efficacy and safety.

Atrial natriuretic peptide for preventing and treating acute kidney injury

19 Studien (n= 1,861)

ANP may be associated with improved outcomes when used in low doses for preventing AKI and in managing postsurgery AKI. There were no significant adverse events in the prevention studies, however in the high dose ANP treatment studies there were significant increases in hypotension and arrhythmias.

Blood pressure lowering efficacy of alpha blockers for primary hypertension

10 Studien (n=1175)

Based on the limited number of published RCTs, the BP lowering effect of alpha blockers is modest; the estimate of the magnitude of trough BP lowering of -8/-5 mmHg is likely an overestimate. There are no clinically meaningful BP lowering differences between different alpha blockers.

Blood pressure lowering efficacy of coenzyme Q10 for primary hypertension
3 Studien (n=96)
Due to the possible unreliability of some of the included studies, it is uncertain whether or not coenzyme Q10 reduces blood pressure in the long-term management of primary hypertension.

Blood pressure lowering efficacy of diuretics as second-line therapy for primary hypertension
53 Studien (n=15.129)

Thiazides when given as a second-line drug have a dose related effect to lower blood pressure that is similar to when they are added as a first-line drug. This means that the BP lowering effect of thiazides is additive. Loop diuretics appear to have a similar blood pressure lowering effect as thiazides at 1 times the recommended starting dose.

Blood pressure lowering efficacy of loop diuretics for primary hypertension
9 Studien (n=460)

Based on the limited number of published RCTs, the SBP/DBP lowering effect of loop diuretics is modest -8/-4 mmHg and is likely an overestimate due to the high risk of bias in the included studies.

Blood pressure lowering efficacy of reserpine for primary hypertension
4 Studien (n=237)
Reserpine is effective in reducing SBP roughly to the same degree as other first-line antihypertensive drugs. However, we could not make definite conclusions regarding the dose-response pattern because of the small number of included trials

Methyldopa for primary hypertension
12 Studien (n= 595)
Methyldopa lowers blood pressure to varying degrees compared to placebo for patients with primary hypertension. Its effect on clinical outcomes, however, remains uncertain.

Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event

65 Studien (n= 166.206)
Nitrates reduce mortality (4-8 deaths prevented per 1000) at 2 days when administered within 24 hours of symptom onset of an acute myocardial infarction. No mortality benefit was seen when treatment continued beyond 48 hours. Mortality benefit of immediate treatment with ACE inhibitors post MI at 2 days did not reach statistical significance but the effect was significant at 10 days (2-4 deaths prevented per 1000). There is good evidence for lack of a mortality benefit with immediate or short-term treatment with beta-blockers and calcium channel blockers for acute myocardial infarction.

Carotid endarterectomy for carotid stenosis in patients selected for coronary artery bypass graft surgery http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006074/frame.html
Keine passenden Studien

Chinese herbal medicines for people with impaired glucose tolerance or impaired fasting blood glucose
16 Studien (n=1391)
The positive evidence in favour of Chinese herbal medicines for the treatment of IGT or IFG is constrained by the following factors: lack of trials that tested the same herbal medicine, lack of details on co-interventions, unclear methods of randomisation, poor reporting and other risks of bias.

Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation
4 Studien (n= 481)
Conventional cooling methods to induce mild therapeutic hypothermia seem to improve survival and neurologic outcome after cardiac arrest. Our review supports the current best medical practice as recommended by the International Resuscitation Guidelines.

Homocysteine lowering interventions for preventing cardiovascular events
8 Studien (n=24.210)
Results from available published trials suggest that there is no evidence to support the use of HLI to prevent cardiovascular events. We found no evidence that homocysteine-lowering interventions, in the form of supplements of vitamins B6, B9 or B12 given alone or in combination, at any dosage compared with placebo or standard care, prevents myocardial infarction, stroke, or reduces total mortality in participants at risk or with established cardiovascular disease.

Subcutaneous unfractionated heparin for the initial treatment of venous thromboembolism
15 Studien (n=3054)
Subcutaneous unfractionated heparin for the treatment of venous thromboembolism cannot be considered non-inferior to other treatment modalities in terms of recurrent DVT and PE at three months, but seems as safe and effective with regards to rates of major bleeding and death.

Vitamin D compounds for people with chronic kidney disease not requiring dialysis
16 Studien (n=894)
There are not sufficient data to determine the effect of vitamin D compounds on mortality and cardiovascular outcomes in people with CKD not requiring dialysis. While vitamin D compounds reduce serum PTH (49.3 pg/mL (5.6 pmol/L)) compared with placebo, the relative clinical benefits of PTH lowering versus treatment-related increases in serum phosphorus and calcium remain to be understood.

Vitamin D compounds for people with chronic kidney disease requiring dialysis
60 Studien (n= 2773)
We confirm that vitamin D compounds suppress PTH in people with CKD and requiring dialysis although treatment is associated with clinical elevations in serum phosphorus and calcium. All studies were inadequately powered to assess the effect of vitamin D on clinical outcomes and until such studies are conducted the relative importance of changes in serum PTH, phosphorus and calcium resulting from vitamin D therapy remain unknown. Observational data showing vitamin D compounds may be associated with improved survival in CKD need to be confirmed or refuted in specifically designed RCTs.

Infektion

Drugs for preventing malaria in travellers
8 Studien (n=4240)
Atovaquone-proguanil and doxycycline are the best tolerated regimens, and mefloquine is associated with adverse neuropsychiatric outcomes.

Interventions for educating traditional healers about STD and HIV medicine
2 Studien (n= 311)
Two studies met the inclusion criteria for this review. Although these studies reported some positive outcomes, the few studies and methodological heterogeneity limits the conclusions that can be drawn about the effectiveness of HIV training programs aimed at traditional healers.

Prophylactic antibiotics for penetrating abdominal trauma
Keine geeigneten Studien

Interventions for HIV-associated nephropathy
Keine geeigneten Studien

Interventions for prevention of post-operative recurrence of Crohn's disease
23 Studien
There are insufficient randomised controlled trials of infliximab, budesonide, tenovil and interleukin-10 to draw conclusions. Nitro-imidazole antibiotics, mesalamine and immunosuppressive therapy with azathioprine/6-MP or infliximab all appear to be superior to placebo for the prevention of post-operative recurrence of Crohn's disease. The cost, toxicity and tolerability of these approaches require careful consideration to determine the optimal approach for post-operative prophylaxis.

Methotrexate for maintenance of remission in Crohn's disease
3 Studien (n= 98)
A pooled analysis (n = 98) including one high quality trail (n = 76) showed that intramuscular methotrexate (15 mg/week) was significantly more effective than placebo for maintenance of remission in Crohn's disease (OR 3.11; 95% CI 1.31 to 7.41; P = 0.01).

Specialist nursing interventions for inflammatory bowel disease
1 Studie style=""> (n= 100)
Although specialist nurse counselling interventions might provide benefit for IBD patients the one included study was of low quality and the results of this study should be interpreted with caution.

Oral potassium iodide for the treatment of sporotrichosis
Keine geeigneten Studien

Vaccines for preventing invasive salmonella infections in people with sickle cell disease
Keine geeigneten Studien

Antibiotic therapy for Shigella dysentery
16 Studien (n=1748)
Antibiotics reduce the duration of Shigella dysentery.
Regularly updated local or regional antibiotic sensitivity patterns to different species and strains of Shigella are required to guide empiric therapy. More trials adhering to standard guidelines are required to evaluate the role of antibiotics in the treatment of severe forms of Shigella dysentery and in groups who are at high risk of complications.

Kinder

Corticosteroids for preventing neonatal respiratory morbidity after elective caesarean section at term
1 Studie (n=942 )
The results from the single trial are promising, but more studies with larger samples are needed to investigate the effect of prophylactic steroids in the incidence of neonatal complications per se.

Diclofenac for acute pain in children
Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.

Manipulative interventions for reducing pulled elbow in young children
3 Studien (n=313)
There is limited evidence from three small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. However, only a small difference in effectiveness was found.

Protein-containing synthetic surfactant versus protein-free synthetic surfactant for the prevention and treatment of respiratory distress syndrome
1 Studie
In the one trial comparing protein containing synthetic surfactants compared to protein free synthetic surfactant for the prevention of RDS, no statistically different clinical differences in death and chronic lung disease were noted. Clinical outcomes between the two groups were generally similar although the group receiving protein containing synthetic surfactants did have decreased incidence of respiratory distress syndrome.

Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department
4 Studien (n=1598)
Current evidence is insufficient, although promising, to support routine rapid viral testing as a means to reduce antibiotic use in pediatric EDs. Results suggest that rapid viral testing may be beneficial but are not statistically significant due to lack of power.

Speech therapy for children with dysarthria acquired before three years of age
Keine geeigneten Studien

Augen

Conventional occlusion versus pharmacologic penalization for amblyopia
3 Studien (n=525)
Both conventional occlusion and atropine penalization produce visual acuity improvement in the amblyopic eye. Atropine penalization appears to be as effective as conventional occlusion, although the magnitude of improvement differed among the three trials. Atropine penalization can be used as first line treatment for amblyopia.

Educational interventions for the prevention of eye injuries
5 Studien
The included studies do not provide reliable evidence that educational interventions are effective in preventing eye injuries. There is a need for well-conducted RCTs with adequate allocation concealment and masking (blinding). Studies should have a longer follow-up time and more studies need to be conducted in low and middle-income countries.

Antiangiogenic therapy with anti-vascular endothelial growth factor modalities for diabetic macular oedema
4 kleine Studien
There is not sufficient high quality evidence from large RCTs supporting the use of either single or multiple anti-VEGF intravitreal injections to treat DMO. Results from ongoing studies on several compounds should assess not only treatment efficacy but also, if a benefit is found, the number of injections needed for maintenance and long-term safety.

Tamponade in surgery for retinal detachment associated with proliferative vitreoretinopathy
2 kleine Studien
The use of either C₃F₈ or silicone oil appears reasonable for most patients with RD associated with PVR. Because there do not appear to be any major differences in outcomes between the two agents, the choice of a tamponade agent should be individualized for each patient.

Krebs

Adjuvant radiotherapy and chemoradiation after surgery for cervical cancer
2 Studien (n= 397)
We found evidence, of moderate quality, that radiation decreases the risk of disease progression compared with no further treatment, but little evidence that it might improve overall survival. The evidence on serious adverse events was equivocal.

Cryotherapy for hepatocellular carcinoma
Keine geeigneten Studien

Selective internal radiation therapy for liver metastases from colorectal cancer
1 Studie (n=21)
There is a need for well designed, adequately powered phase III trials assessing the effect of SIRT when used with modern combination chemotherapy regimens. Further studies are also needed for patients with refractory disease with a particular focus on the impact on quality of life.

Interventions for central giant cell granuloma (CGCG) of the jaws
1 Studie
We did not find RCTs evaluating the effects of primary surgical versus primary non-surgical interventions for central giant cell granuloma of the jaws. Although a number of non-surgical therapies have been proposed for treating central giant cell granuloma of the jaws, our review did not identify evidence from RCTs to support their use. More research is needed on this topic.

Interventions for dysphagia in oesophageal cancer
40 Studien (n=2542)
Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Surgical excision margins for primary cutaneous melanoma
5 Studien (n=3297)
This systematic review summarises the evidence regarding width of excision margins for primary cutaneous melanoma. None of the five published trials, nor our meta-analysis, showed a statistically significant difference in overall survival between narrow or wide excision.
Current randomised trial evidence is insufficient to address optimal excision margins for primary cutaneous melanoma.

Knochen

Doxycycline for osteoarthritis of the knee or hip
1 Studie (n=431)
The symptomatic benefit of doxycycline is minimal to non-existent. The small benefit in terms of joint space narrowing is of questionable clinical relevance and outweighed by safety problems. Doxycycline should not be recommended for the treatment of osteoarthritis of the knee or hip.

Abatacept for rheumatoid arthritis
7 Studien (n=2908)
There is moderate-level evidence that abatacept is efficacious and safe in the treatment of rheumatoid arthritis. Abatacept should not be used in combination with other biologics to treat rheumatoid arthritis. The withdrawal and toxicity profile appears acceptable at the present time but further long-term studies and post-marketing surveillance are required to assess harms and sustained efficacy.

Biologics for rheumatoid arthritis: an overview of Cochrane reviews
6 Cochrane Reviews
Based upon indirect comparisons, anakinra seemed less efficacious than etanercept, adalimumab and rituximab and etanercept seemed to cause fewer withdrawals due to adverse events than adalimumab, anakinra and infliximab. Significant heterogeneity in characteristics of trial populations imply that these finding must be interpreted with caution. These findings can inform physicians and patients regarding their choice of biologic for treatment of RA.

Multidisciplinary rehabilitation for older people with hip fractures
13 Studie (n=2498)
While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant.
Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components.

Assistive technology for rheumatoid arthritis
1 Studie (n=29)
Only one trial met the inclusion criteria for this review. Thus, there is very limited evidence for the effect of assistive technology for adults with rheumatoid arthritis and, therefore, an urgent need for high-quality research addressing the effectiveness of commonly used interventions.

Oral or transdermal opioids for osteoarthritis of the knee or hip
10 Studie (n=2268)
The small to moderate beneficial effects of non-tramadol opioids are outweighed by large increases in the risk of adverse events. Non-tramadol opioids should therefore not be routinely used, even if osteoarthritic pain is severe.

S-Adenosylmethionine for osteoarthritis of the knee or hip
4 Studien (n=565)
The current systematic review is inconclusive, hampered by the inclusion of mainly small trials of questionable quality. The effects of SAMe on both pain and function may be potentially clinically relevant and, although effects are expected to be small, deserve further clinical evaluation in adequately sized randomised, parallel-group trials in patients with knee or hip osteoarthritis. Meanwhile, routine use of SAMe should not be advised.

Exercise

Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis
8 Studien
Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA.

Constraint-induced movement therapy for upper extremities in stroke patients
19 Studien (n= 619)
CIMT is a multifaceted intervention: the restriction to the normal limb is accompanied by a certain amount of exercise of the appropriate quality. It is associated with a moderate reduction in disability assessed at the end of the treatment period. However, for disability measured some months after the end of treatment, there was no evidence of persisting benefit. Further randomised trials, with larger sample sizes and longer follow up, are justified.

Atmung

Regular treatment with formoterol versus regular treatment with salmeterol for chronic asthma: serious adverse events
4 Studien (n=1372)
Four studies have been identified comparing regular formoterol to regular salmeterol (without randomised inhaled corticosteroids, but all subjects were on regular background inhaled corticosteroids). The events were infrequent and consequently too few patients have been studied to allow any firm conclusions to be drawn about the relative safety of formoterol and salmeterol. Asthma-related serious adverse events were rare, and there were no reported asthma-related deaths.

Vitamin D supplementation for cystic fibrosis
2 Studien (n=41)
There is no evidence of benefit or harm in the limited number of small-sized published trials. Adherence to relevant CF guidelines on vitamin D should be considered until further evidence is available.

Urologie

Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones
3 Studien ((n=214)
Results from three small studies, with low methodological quality, indicated ESWL is less effective for lower pole kidney stones than PCNL but not significantly different from RIRS. Hospital stay and duration of treatment was less with ESWL. More RCTs are required to investigate the effectiveness and complications of ESWL for kidney stones compared to PCNL or RIRS.

Alpha blockers prior to removal of a catheter for acute urinary retention in adult men
5 Studien
The limited available evidence suggests that alpha blockers increase success rates of TWOC. Alpha blocker side effects are low and comparable to placebo. It is uncertain whether alpha blockers reduce the risk of recurrent urinary retention and need for prostate surgery.

Naftopidil for the treatment of lower urinary tract symptoms compatible with benign prostatic hyperplasia
8 Studien (n=744)
There are no data from placebo controlled trials regarding the efficacy of naftopidil in men with symptomatic BPH.

Neurologie/Psychiatrie

Antioxidants and other pharmacological treatments for Friedreich ataxia
1 Studie
No RCT using idebenone or any other pharmacological treatment has shown significant benefit on neurological symptoms associated with Friedreich ataxia. Idebenone has shown a positive effect on left ventricular heart mass but no research on clinical relevance of this change has been done.

Cannabinoids for Tourette's Syndrome
2 Studien (n= 28)
Not enough evidence to support the use of cannabinoids in treating tics and obsessive compulsive behaviour in people with Tourette's syndrome.

Duloxetine for treating painful neuropathy or chronic pain
6 Studien (n= 2220)
There is moderately strong evidence that duloxetine 60 mg and 120 mg daily are efficacious for treating pain in diabetic peripheral neuropathy and fibromyalgia but 20 mg daily is not. Minor side effects are common at therapeutic doses but serious side effects are rare. Direct comparisons of duloxetine with other antidepressants and with other drugs already shown to be efficacious in neuropathic pain would be appropriate and should include unbiased economic analyses.

Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation
4 Studien (n= 481)
Conventional cooling methods to induce mild therapeutic hypothermia seem to improve survival and neurologic outcome after cardiac arrest. Our review supports the current best medical practice as recommended by the International Resuscitation Guidelines.

Magnetic resonance imaging versus computed tomography for detection of acute vascular lesions in patients presenting with stroke symptoms
8 Studien (n= 308)
DWI appears to be more sensitive than CT for the early detection of ischaemic stroke in highly selected patients. However, the variability in the quality of included studies and the presence of spectrum and incorporation biases render the reliability and generalisability of observed results questionable.

Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease
2 Studien (n= 54)
Evidence from a single randomised trial of non-invasive ventilation in 41 participants suggests that it significantly prolongs survival and improves or maintains quality of life in people with ALS. Survival and some measures of quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment.

Multidisciplinary care for adults with amyotrophic lateral sclerosis or motor neuron disease
Keine geeigneten Studien
In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date is based on three ‘low’ and two ‘very low quality’ observational studies. These suggest 'very low quality evidence' for an advantage for mental health domains (only) of quality of life without increasing healthcare costs, and 'low level quality' evidence for reduced hospitalisation for MDC in low-intensity outpatient settings; and 'very low quality' evidence for improved disability in high-intensity settings.

Speech therapy for children with dysarthria acquired before three years of age
Keine geeigneten Studien
We found no firm evidence of the effectiveness of speech and language therapy to improve the speech of children with early acquired dysarthria.

Monetary incentives for schizophrenia
1 Studie (n= 25)

Monoamine oxidase B inhibitors versus other dopaminergic agents in early Parkinson's disease
2 Studien (n= 593)
MAO-B inhibitors are one option for the early treatment of PD although they have weaker symptomatic effects than levodopa and dopamine agonists. They may reduce the rate of motor fluctuations compared with initial levodopa therapy and may have fewer significant adverse effects than the older agonists but data are too few to provide reliable conclusions.

Oxcarbazepine versus carbamazepine monotherapy for partial onset seizures
6 Studien (n= 2220)

Psychosocial interventions for the prevention of disability following traumatic physical injury
6 Studien (n= 2220)

Constraint-induced movement therapy for upper extremities in stroke patients
19 Studien (n= 619)
CIMT is a multifaceted intervention: the restriction to the normal limb is accompanied by a certain amount of exercise of the appropriate quality. It is associated with a moderate reduction in disability assessed at the end of the treatment period. However, for disability measured some months after the end of treatment, there was no evidence of persisting benefit. Further randomised trials, with larger sample sizes and longer follow up, are justified.

Risperidone dose for schizophrenia
There is still lack of strong evidence for an optimal dose for clinical practice. The quality of trials suggests that an over estimate of effect is likely and we think this is most probably for the mid-range doses.

Special care units for dementia individuals with behavioural problems
Keine geeigneten Studien
There are no identified RCTs investigating the effects of SCUs on behavioural symptoms in dementia, and no strong evidence of benefit from the available non-RCTs

Traditional Chinese medicinal herbs for the treatment of idiopathic chronic fatigue and chronic fatigue syndrome
Keine geeigneten Studien
Although studies examining the use of TCM herbal products for chronic fatigue were located, methodologic limitations resulted in the exclusion of all studies. Of note, many of the studies labelled as RCTs and conducted in China did not utilize rigorous randomization procedures. Improvements in methodology in future studies is required for meaningful synthesis of data.

Ziprasidone versus other atypical antipsychotics for schizophrenia
9 Studien (n= 3361)
Ziprasidone may be a slightly less efficacious antipsychotic drug than amisulpride, olanzapine and risperidone. Its main advantage is the low propensity to induce weight gain and associated adverse effects. However, the high overall rate of participants leaving the studies early limits the validity of any findings.

Ultrasound guidance for peripheral nerve blockade
18 Studien (n= 1344)
In experienced hands, ultrasound provides at least as good success rates as other methods of peripheral nerve location. Individual studies have demonstrated that ultrasound may reduce complication rates and improve quality, performance time, and time to onset of blocks. Due to wide variations in study outcomes we chose not to combine the studies in our analysis.

Chirurgie

Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection
9 Studien (n= 587)
None of the interventions seem to decrease peri-operative morbidity or offer any long-term survival benefit.

Pharmacological interventions to decrease blood loss and blood transfusion requirements for liver resection
6 Studien (n= 849)
None of the interventions seem to decrease peri-operative morbidity or offer any long-term survival benefit.

Pharmacological interventions versus no pharmacological intervention for ischaemia reperfusion injury in liver resection surgery performed under vascular control
15 Studien

Processed versus fresh frozen bone for impaction bone grafting in revision hip arthroplasty
Keine geeigneten Studien
Good quality randomised controlled trials are required in this area so that a surgeon’s choice of bone graft can be informed by evidence rather than personal preference.

Shouldice technique versus other open techniques for inguinal hernia repair
16 Studien (n= 2566)
Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low.

Surgical interventions for anterior shoulder instability in adults
3 Studien (n= 184)
There is insufficient evidence from randomised trials comparing arthroscopic with open surgery for treating anterior shoulder instability.

Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle
3 kleine Studien
There is limited evidence, from single trials only, regarding the effectiveness of different methods of surgical fixation of fractures and non-union of the middle third of the clavicle.

Arthrocentesis and lavage for treating temporomandibular joint disorders
2 Studien (n= 81)
There is insufficient, consistent evidence to either support or refute the use of arthrocentesis and lavage for treating patients with temporomandibular joint disorders.

>Supplemental perioperative steroids for surgical patients with adrenal insufficiency

2 Studien (n=37)
Owing to the small number of patients, the results may not be representative. Based on current available evidence, we are unable to support or refute the use of supplemental perioperative steroids for patients with adrenal insufficiency during surgery.

Zahn

Adhesively bonded versus non-bonded amalgam restorations for dental caries
1 Studie (n = 31)
There is no evidence to either claim or refute a difference in survival between bonded and non-bonded amalgam restorations. This review only found one methodologically sound but somewhat under-reported trial. This trial did not find any significant difference in the in-service performance of moderately sized adhesively bonded amalgam restorations, in terms of their survival rate and marginal integrity, in comparison to non-bonded amalgam restorations over a 2-year period. In view of the lack of evidence on the additional benefit of adhesively bonding amalgam in comparison with non-bonded amalgam, it is important that clinicians are mindful of the additional costs that may be incurred.

Interventions for cleaning dentures in adults
Although six RCTs were included in this review, the wide range of different interventions and outcome variables did not permit pooling of data in a meta-analysis.
There is a lack of evidence about the comparative effectiveness of the different denture cleaning methods considered in this review. Few well designed RCTs were found.

Frauen

Fundal pressure during the second stage of labour
1 Studie (n= 500)
There is no evidence available to conclude on beneficial or harmful effects of manual fundal pressure. Good quality randomised controlled trials are needed to study the effect of manual fundal pressure. Fundal pressure by an insufflatable belt during the second stage of labour does not appear to increase the rate of spontaneous vaginal births in women with epidural analgesia. There is insufficient evidence regarding safety for the baby. The effects on the maternal perineum are inconclusive.

Interventions for preventing unintended pregnancies among adolescents
41 Studien (n=95.662)
Combination of educational and contraceptive interventions appears to reduce unintended pregnancy among adolescents. Evidence for program effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen
2 Studien
The Mirena LNG-IUS appears to prevent the development of benign endometrial polyps in breast cancer patients taking tamoxifen, over a one-year period. There is no clear evidence from the available randomised controlled trials that LNG-IUS prevents endometrial hyperplasia or adenocarcinoma in these patients. Larger studies are necessary to assess the effects of LNG-IUS in preventing endometrial hyperplasia and endometrial cancer, and to determine whether LNG-IUS might have an impact on the risk of breast cancer recurrence.

Medical treatments for idiopathic thrombocytopenic purpura during pregnancy
1 Studie (n=38)
Current evidence indicates that compared to no medication, betamethasone did not reduce the risk of neonatal thrombocytopenia and neonatal bleeding in ITP during pregnancy. There is insufficient evidence to support the use of betamethasone for treating ITP. This Cohrane review does not provide evidence about other medical treatments for ITP during pregnancy.

Routine pre-pregnancy health promotion for improving pregnancy outcomes
4 Studien (n=2300)
There is little evidence on the effects of pre-pregnancy health promotion and much more research is needed in this area. There is currently insufficient evidence to recommend the widespread implementation of routine pre-pregnancy health promotion for women of childbearing age, either in the general population or between pregnancies.

Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women
62 Studien (n=7101)
The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short term but with less postoperative complications. Women were less likely to be continent after operations performed via the obturator (rather than retropubic) route, but they had fewer complications. Most of the trials had short term follow up and the quality of the evidence was variable.

Nitric oxide donors for cervical ripening in first-trimester surgical abortion
8 Studien (n=718)
NO donors are inferior to prostaglandins for first-trimester cervical ripening, and associated with more side effects. NO donors are comparable to placebo and no treatment for cervical ripening.

Post-embryo transfer interventions for in vitro fertilization and intracytoplasmic sperm injection patients
There is insufficient evidence to support a certain amount of time for women to remain recumbent following ET, or to support the use of fibrin sealants. Finally, there is limited evidence to support the use of mechanical closure of the cervical canal following ET.

Techniques for preparation prior to embryo transfer
At the time of ET, there was no evidence of benefit with the following interventions: full bladder, removal of cervical mucus, flushing the endocervical canal or the endometrial cavity. We did not identify any eligible studies for dummy transfer, changing patient position, the use of a tenaculum, or embryo afterloading.

Probiotics for the treatment of bacterial vaginosis

The results do not provide sufficient evidence for or against recommending probiotics for the treatment of BV. The metronidazole/probiotic regimen and probiotic/estriol perparation appear promising but well-designed randomized controlled trials with standardized methodologies and larger patient size are needed.

Schmerz

Single dose oral fenbufen for acute postoperative pain in adults
1 Studie (n=90)
In the absence of evidence of efficacy for oral fenbufen in acute postoperative pain, its use in this indication is not justified at present.

Single dose oral ketoprofen and dexketoprofen for acute postoperative pain in adults
21 Studien (n>2000)
Ketoprofen at doses of 25 mg to 100 mg is an effective analgesic in moderate to severe acute postoperative pain with an NNT for at least 50% pain relief of 3.3 with a 50 mg dose. This is similar to that of commonly used NSAIDs such as ibuprofen (NNT 2.5 for 400 mg dose) and diclofenac (NNT 2.7 at 50 mg dose). Duration of action is about 5 hours. Dexketoprofen is also effective with NNTs of 3.2 to 3.6 in the dose range 10 mg to 25 mg. Both drugs were well tolerated in single doses.

Single dose oral lornoxicam for acute postoperative pain in adults
3 Studien (n= 628)
Oral lornoxicam is effective at treating moderate to severe acute postoperative pain, based on limited data. Adverse events did not differ significantly from placebo.

Single dose oral meloxicam for acute postoperative pain in adults
Keine geeigneten Studien
In the absence of evidence of efficacy, at present, for oral meloxicam in acute postoperative pain, its use in this indication is not justified.

Single dose oral nabumetone for acute postoperative pain in adults
Keine geiegneten Studien
In the absence of evidence of efficacy, at present, for oral nabumetone in acute postoperative pain, its use in this indication is not justified.

Single dose oral sulindac for acute postoperative pain in adults
Keine geiegneten Studien
In the absence of evidence of efficacy, at present, for oral sulindac in acute postoperative pain, its use in this indication is not justified.

Single dose oral tiaprofenic acid for acute postoperative pain in adults
Keine geiegneten Studien
In the absence of evidence of efficacy for oral tiaprofenic acid in acute postoperative pain, its use in this indication is not justified at present.

Topical capsaicin for chronic neuropathic pain in adults
6 Studien (n= 389)
Capsaicin, either as repeated application of a low dose (0.075%) cream, or a single application of a high dose (8%) patch may provide a degree of pain relief to some patients with painful neuropathic conditions. Local skin irritation, which is often mild and transient but may lead to withdrawal, is common. Systemic adverse effects are rare. Estimates of benefit and harm are not robust due to limited amounts of data for different neuropathic conditions and inconsistent outcome definition.

Diverses

Amifostine for salivary glands in high-dose radioactive iodine treated differentiated thyroid cancer
2 Studien (n=130)
Results from two randomised controlled clinical trials suggest that the amifostine has no significant radioprotective effects on salivary glands in high-dose radioactive iodine treated differentiated thyroid cancer patients. Moreover, no health-related quality of life and other patient-oriented outcomes were evaluated in the two included trials. Randomised controlled clinical trials with low risk of bias investigating patient-oriented outcomes are needed to guide treatment choice.

Audit filters for improving processes of care and clinical outcomes in trauma systems
We were unable to identify any studies of sufficient methodological quality to draw conclusions regarding the effectiveness of audit filters as a performance improvement intervention in trauma systems.

The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries
6 Studien
Conditional cash transfer programmes have been the subject of some well-designed evaluations, which strongly suggest that they could be an effective approach to improving access to preventive services. Their replicability under different conditions - particularly in more deprived settings - is still unclear because they depend on effective primary health care and mechanisms to disburse payments. Further rigorous evaluative research is needed, particularly where CCTs are being introduced in low income countries, for example in Sub-Saharan Africa or South Asia.

The impact of contracting out on health outcomes and use of health services in low and middle-income countries
Three studies suggest that contracting out may be an appropriate response to scale up service delivery in particular settings, such as post-conflict or fragile states. Evidence was not presented on whether this approach was more effective than making a similar investment in the public sector, as there was not an exact control available in any of the settings. In addition, the introduction of non-state providers into some settings and not others also brings many potentially confounding variables, such as the presence of additional management expertise or expatriate doctors, which may improve drug supply or increase utilisation.

Mobile phone-based interventions for smoking cessation
4 Studien
The current evidence shows no effect of mobile phone-based smoking cessation interventions on long-term outcome. While short-term results are positive, more rigorous studies of the long-term effects of mobile phone-based smoking cessation interventions are needed.

Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade
18 Studien (n=1321)
Sugammadex was shown to be effective in reversing rocuronium-induced neuromuscular blockade. This review has found no evidence of a difference in the instance of unwanted effects between sugammadex, placebo or neostigmine. These results need to be confirmed by future trials on larger patient populations and with more focus on patient-related outcomes.

Pancreatic enzymes for chronic pancreatitis
10 Studien (n=361)
The role of pancreatic enzymes for abdominal pain, weight loss, steatorrhoea, analgesic use and quality of life in patients with chronic pancreatitis remains equivocal. Good quality, adequately powered studies are much warranted.

Pentoxifylline for alcoholic hepatitis
5 Studien (336)
The current available data may indicate a possible positive intervention effect of pentoxifylline on all-cause mortality and mortality due to hepatorenal syndrome, and conversely, an increase in serious and non-serious adverse events. However, the evidence is not firm; no conclusions can be drawn regarding whether pentoxifylline has a positive, negative, or neutral effect on participants with alcoholic hepatitis.

Vasodilators and vasoactive substances for idiopathic sudden sensorineural hearing loss

3 Studien (n0189)
The effectiveness of vasodilators in the treatment of ISSHL remains unproven. The included studies were of relatively poor quality and the number of patients included was small. Moreover, there were differences in the type, dosage and duration of vasodilator used in each study. Due to the degree of heterogeneity the results could not be combined to reach a conclusion.

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