Die 5 Minuten Evidenz - Cochrane Ausgabe 2/2010

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Ausgabe 2/2010 der Cochrane Library

 


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Herz, Kreislauf, CVD Infektion Kinder
Aktivität Augen Krebs
Sucht Atmung Urologie
Frauen Chirurgie Neurologie/Psychiatrie
Schmerz Zahn Diverses 



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Herz Kreislauf, CVD

Fibrinolytic agents for peripheral arterial occlusion
5 Studien (n=687)
There is some evidence to suggest that intra-arterial rt-PA is more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion. There was no evidence that rt-PA was more effective than urokinase for patients with peripheral arterial occlusion and some evidence that initial lysis may be more rapid with rt-PA, depending on the regime. Incidences of haemorrhagic complications were not statistically significantly greater with rt-PA than with other regimes. However, all of the findings come from small studies and a general paucity of results means that it is not possible to draw clear conclusions.

Service organisation for the secondary prevention of ischaemic heart disease in primary care 
11 Studien (n= 12.074)
There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured.

Direct thrombin inhibitors versus vitamin K antagonists or low molecular weight heparins for prevention of venous thromboembolism following total hip or knee replacement  
14 Studien (n=21.642)
Direct thrombin inhibitors are as effective in the prevention of major venous thromboembolism in THR or TKR as LMWH and vitamin K antagonists. However, they show higher mortality and cause more bleeding than LMWH. No severe hepatic complications were reported in the analysed studies. Use of ximelagatran is not recommended for VTE prevention in patients who have undergone orthopedic surgery. More studies are necessary regarding dabigatran. 

Cerebrolysin for acute ischaemic stroke
Studie (n=146)
There is not enough evidence to evaluate the effect of cerebrolysin on survival and dependency in people with acute ischaemic stroke. High-quality and large-scale randomised controlled trials may help to gain a better understanding of the potential value of cerebrolysin in acute ischaemic stroke.

Self-monitoring and self-management of oral anticoagulation 
18 Studien (n=4723)
Compared to standard monitoring, patients who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. The number of thromboembolic events and mortality were decreased without increases in harms. However, self-monitoring or self-management were not feasible for up to half of the patients requiring anticoagulant therapy. Reasons included patient refusal, exclusion by their general practitioner, and inability to complete training.

Traditional Chinese herbal products for stable angina  
3 Studien (n=216)
There is currently insufficient evidence for effectively treating stable angina pectoris with any of the examined TCHP in this review, due to the small number of included studies and participants. Therefore, TCHP should be used with caution. High quality randomised trials with similar interventions are required to strengthen the evidence for the effectiveness and safety of Chinese medicinal herbs in angina pectoris.   

Prostaglandin E1 for preventing the progression of diabetic kidney disease 
6 Studien (n=271)
PGE1 may have positive effects on DKD by reducing UAER, decreasing albuminuria and lessening proteinuria, with no obvious serious adverse events. However, limited by the poor methodological quality of the included studies and the small number of participants, there is currently insufficient evidence for determining if PGE1 could be used for preventing the progression of DKD. Large, properly randomised, placebo-controlled, double-blind studies are urgently needed.

Drug-eluting stents versus bare metal stents for angina or acute coronary syndromes  
47 RCTs (n=14.500)
Drug-eluting stents releasing sirolimus, paclitaxel, dexamethasone and zotarolimus reduce composite cardiac events. However, this reduction is due largely to reductions in repeat revascularisation rates as there is no evidence of a significant effect on rates of death, MI or thrombosis. The increased cost of drug-eluting stents and lack of evidence of their cost-effectiveness means that various health funding agencies are having to limit or regulate their use in relation to price premium.

 

Infektion

Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women 
3 RCTs und observationale Evidenz
In ART-eligible pregnant women with HIV infection, ART is a safe and effective means of providing maternal virologic suppression, decreasing infant mortality, and reducing MTCT. Specifically, AZT/3TC/NVP, AZT/3TC/LPV-r, and AZT/3TC/ABC have been shown to decrease MTCT. More research is needed regarding the use of specific regimens and their maternal and infant side-effect profiles.

Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults 
2 Studien (n=1065)
There is evidence of moderate quality that initiating ART at CD4 levels higher than 200 or 250 cells/µL reduces mortality rates in asymptomatic, ART-naive, HIV-infected people. Practitioners and policy-makers may consider initiating ART at levels ≤ 350 cells/µL for patients who present to health services and are diagnosed with HIV early in the infection.

Neuraminidase inhibitors for the treatment of influenza infection in people with cystic fibrosis    
Keine geeigneten Studien
We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the efficacy of neuraminidase inhibitors for the treatment of influenza infection in people with cystic fibrosis. The absence of high level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately powered, randomised controlled clinical trials.

Saline nasal irrigation for acute upper respiratory tract infections  
3 Studien (n=618)
Included trials were too small and had too high a risk of bias to be confident about the possible benefits of nasal saline irrigation in acute URTIs. Future trials should involve much larger numbers of participants and be rigorously designed and controlled.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters  
6 Studien (n=3.455)
The review found no conclusive evidence of benefit in changing catheters every 72 to 96 hours. Consequently, health care organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would also be welcomed by patients, who would be spared the unnecessary pain of routine re-sites in the absence of clinical indications.

Topical silver for preventing wound infection      
26 Studien (n=2066)
There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection; some poor quality evidence for SSD (silver sulphadiazine) suggests the opposite.

Washout policies in long-term indwelling urinary catheterisation in adults 
5 Studien (n=242)
The data from five trials comparing differing washout policies were sparse and trials were generally of poor quality or poorly reported. The evidence was too scanty to conclude whether or not washouts were beneficial. In the first instance we require further rigorous, high quality trials with adequate power to detect any benefit from washout being performed as opposed to none. Then trials comparing different washout solutions, washout volumes, frequencies/timings and routes of administration are needed.

Pegloticase for chronic gout      
1 Phase-II RCT (n=41)
There are no published double-blind, placebo-controlled RCTs of pegloticase.

Indoor residual spraying for preventing malaria  
6 Studien
In conclusion, although IRS programmes have shown impressive success in malaria reduction throughout the world, there are too few well-run trials to be able to quantify the effects of IRS in areas with different malaria transmission, or to properly compare IRS and ITN.  High-quality and long-duration trials on a large scale, done in areas where there has been little or no mosquito control are still urgently required.

Optimal monitoring strategies for guiding when to switch first-line antiretroviral therapy regimens for treatment failure in adults and adolescents living with HIV in low-resource settings  

2 RCTs, 2 Kohorten

Although the quality of the evidence varied from the randomized trials, ranging from very low to moderate, there appeared to be substantial benefits for key outcomes (e.g. mortality, AIDS-defining illness and mortality as a composite endpoint, and unnecessary switches) favoring both immunologic and clinical monitoring or virologic, immunologic, and clinical monitoring versus clinical monitoring alone. Very low-quality evidence from observational studies suggested that virologic, immunologic, and clinical monitoring led to more frequent switching, earlier switching, and switching at higher CD4 counts compared with immunologic and clinical monitoring.

Vaccines for preventing rotavirus diarrhoea: vaccines in use
34 Studien (n=175.944)
Rotarix and RotaTeq are effective vaccines for the prevention of rotavirus diarrhoea. The balance between benefit and harm favours benefit. Ongoing safety monitoring should be continued. Trials comparing LLR with placebo should be conducted and the results made available.

Treatment for leiomyosarcoma and leiomyoma in children with HIV infection  
Keine geigneten Studien
We could not find any RCTs or CCTs of intervention for treating AIDS-associated SMT in children with HIV infection, and currently, the clinical practice of treating SMT in HIV-infected children is based on descriptive studies and simply situational analyses. Thus there is insufficient evidence to establish the efficacy and acceptability of these interventions, and we recommend a case-by-case treatment of patients until evidence becomes available.

 

Atmung

 

Heated humidification versus heat and moisture exchangers for ventilated adults and children      
33 Studien (n=2833)
There is little evidence of an overall difference between HMEs and HHs. However, hydrophobic HMEs may reduce the risk of pneumonia and the use of an HME may increase artificial airway occlusion in certain subgroups of patients. Therefore, HMEs may not be suitable for patients with limited respiratory reserve or prone to airway blockage. Further research is needed relating to hydrophobic versus hygroscopic HMEs and the use of HMEs in the paediatric and neonatal populations. As the design of HMEs evolves, evaluation of new generation HMEs will also need to be undertaken.

Singing for children and adults with cystic fibrosis    
As no studies that met the criteria were found, this review is unable to support or refute the benefits of singing as a therapy for people with cystic fibrosis. Future randomised controlled trials are required to evaluate singing therapy for people with cystic fibrosis.

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients    
11 Studien (n=1.971)
There is some evidence of a reduction in the duration of mechanical ventilation, weaning duration and ICU LOS with use of standardized protocols, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Although some study authors suggest that organizational context may influence outcomes, these factors were not considered in all included studies and therefore could not be evaluated.

Combination inhaled steroid and long-acting beta2-agonist versus tiotropium for chronic obstructive pulmonary disease
3 Studien
Since the proportion of missing outcome data compared to the observed outcome data is enough to induce a clinically relevant bias in the intervention effect, the relative efficacy and safety of combined inhalers and tiotropium remains uncertain. Further large, long-term randomised controlled trials comparing combination therapy to tiotropium are required, including adequate follow-up of all participants randomised (similar to the procedures undertaken in TORCH and UPLIFT). Additional studies comparing alternative inhaled LABA/steroid combination therapies with tiotropium are also required.

 

Kinder

 

Minimally invasive surgery versus open surgery for the treatment of solid abdominal and thoracic neoplasms in children
Keine geeigneten Studien
No RCTs or CCTs evaluating MIS in the treatment of solid intra-thoracic or intra-abdominal neoplasms in children could be identified, therefore no definitive conclusions could be made about the effects of MIS in these patients. Based on the currently available evidence we are not able to give recommendations for the use of MIS in the treatment of solid intra-thoracic or intra-abdominal neoplasms in children. More high quality studies (RCTs and/or CCTs) are needed. To accomplish this, centres specialising in MIS in children should collaborate.

Heliox inhalation therapy for bronchiolitis in infants 
4 Studien (n=84)
Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. Nevertheless, there was no reduction in the rate of intubation, in the need for mechanical ventilation, or in the length of PICU stay. Further studies with homogeneous logistics in their heliox application are needed. Such studies would provide necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.

In-service training for health professionals to improve care of the seriously ill newborn or child in low and middle-income countries (Review) 
2 Studien
There is limited evidence that in-service neonatal emergency care courses improve health-workers’ practices when caring for a seriously ill newborn although there is some evidence of benefit. Rigorous trials evaluating the impact of refresher emergency care training on long-term professional practices are needed. To optimise appropriate policy decisions, studies should aim to collect data on resource use and costs of training implementation.

Inhaled non-steroid anti-inflammatories for children and adults with bronchiectasis      
1 Studie
There is currently insufficient evidence to support or refute the use of inhaled NSAIDs in the management of bronchiectasis in adults or children. One small trial reported a reduction in sputum production and improved dyspnoea in adults with chronic lung disease who were treated with inhaled indomethacin, indicating that further studies on the efficacy of NSAIDs in treating patients with bronchiectasis are warranted. 

Supplementary vitamin E, selenium, cysteine and riboflavin for preventing kwashiorkor in preschool children in developing countries 
1 Studie (n=2.372)
Based on the one available trial, we could draw no firm conclusion for the effectiveness of supplementary antioxidant micronutrients for the prevention of kwashiorkor in pre-school children.

Iron supplementation for breath-holding attacks in children
2 Studien (n=87)
Iron supplementation (at 5 mg/kg/day of elemental iron for 16 weeks) appears to be useful in reducing the frequency and severity of breath-holding attacks. Supplementation is of particular benefit in children with iron deficiency anaemia, responses correlating with the improvements in haemoglobin values. Iron may still be of assistance in children who are not anaemic or who have low, normal haemoglobin levels. Further high-quality randomised control trials of iron supplementation to treat breath-holding attacks in children are required. 

Oral lactoferrin for the prevention of sepsis and necrotizing enterocolitis in preterm infants
1 Studie (n=472)
Oral lactoferrin prophylaxis reduces the incidence of late-onset sepsis in infants weighing less than 1500 g and most effective in infants weighing less than 1000 g. There is no evidence of efficacy of oral lactoferrin (given alone) in the prevention of NEC in preterm neonates.
Well designed, randomized trials should address dosing, duration, type of lactoferrin (bovine or human) prophylaxis in prevention of sepsis and NEC. The effect of exclusive maternal milk feeding should be clarified.

 

Krebs


Angiogenesis-inhibitors for metastatic thyroid cancer  
Keine geeigneten Studien
There is currently no reliable evidence available from randomized controlled trials regarding the benefits and harms of the use of angiogenesis-inhibitors for treating advanced thyroid cancer. Several trials are ongoing.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy
1 Studie
There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Surgical management of localised renal cell carcinoma  
Keine RCT
The main source of evidence for the current practice of laparoscopic excision of renal cancer is drawn from case series, small retrospective studies and very few small randomised controlled trials. The results and conclusions of these studies must therefore be interpreted with caution.

Interventions for non-metastatic squamous cell carcinoma of the skin      
1 Studie (n=65)
Little evidence from RCTs comparing the efficacy of different interventions for primary cutaneous SCCs exists. There is a clear need for well-designed randomised studies in order to improve the evidence base for the management of this condition.

High-dose chemotherapy and autologous haematopoietic stem cell rescue for children with high-risk neuroblastoma
3 RCTs (n=739)
Based on the currently available evidence, myeloablative therapy seems to be a good treatment option for children with high-risk neuroblastoma. It results in higher survival rates than conventional therapy, although possible higher levels of adverse effects should be kept in mind. A definitive conclusion regarding the effect of myeloablative therapy in different subgroups is not possible. This systematic review only allows a conclusion on the concept of myeloablative therapy; no conclusions can be made regarding the best treatment strategy. Future trials on the use of myeloablative therapy for high-risk neuroblastoma should focus on identifying the most optimal induction and/or myeloablative regimen. The best study design to answer these questions is a RCT. These RCTs should be performed in homogeneous study populations (for example, regarding stage of disease and patient age) and have a long-term follow up. Different risk groups should be taken into account.

Chemotherapy and supportive care versus supportive care alone for advanced non-small cell lung cancer   
6 RCTs (n=2714)
All trials were of good methodological quality with no risk of bias. This meta-analysis of chemotherapy in the supportive care setting demonstrates that chemotherapy improves overall survival in all patients with advanced NSCLC. Patients who are fit enough and wish to receive it should be offered chemotherapy.

 

Neurologie/Psychiatrie

 

Antidepressants for depression in physically ill people      
51 Studien (n=3.603)
This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.

Early psychological interventions to treat acute traumatic stress symptoms  
15 Studien
There was evidence that individual TF-CBT was effective for individuals with acute traumatic stress symptoms compared to both waiting list and supportive counselling interventions. The quality of trials included was variable and sample sizes were often small. There was considerable clinical heterogeneity in the included studies and unexplained statistical heterogeneity observed in some comparisons. This suggests the need for caution in interpreting the results of this review. Additional high quality trials with longer follow up periods are required to further test TF-CBT and other forms of psychological intervention.´

Fluvoxamine versus other anti-depressive agents for depression
54 Studien (n = 5.122)
We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles.

Olanzapine versus other atypical antipsychotics for schizophrenia 
50 Studien (n = 9.476)
Olanzapine may be a somewhat more efficacious drug than some other second generation antipsychotic drugs. This small superiority in efficacy needs to be weighed against a larger weight gain and associated metabolic problems than most other second generation antipsychotic drugs, except clozapine. These conclusions are tentative due to the large number of people leaving the studies early which possibly limits the validity of the findings.

 

Physical health care monitoring for people with serious mental illness      
Keine RCTs
There is no evidence from randomised trials to support current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.´

Pharmacological treatment of depression in patients with a primary brain tumour    
Keine RCTs
No high-quality studies have examined the value of any drug treatment of depression in patients with primary brain tumours. Detailed prospective studies and RCTs are needed to inform the safe and effective treatment of this common and important complication of brain tumours.

Tinnitus Retraining Therapy (TRT) for tinnitus      
1 Studie (n=123)
A single, low-quality randomised controlled trial suggests that TRT is much more effective as a treatment for patients with tinnitus than tinnitus masking.

Aspirin with or without an antiemetic for acute migraine headaches in adults
13 Studien (n=4.222)
Aspirin 1000 mg is an effective treatment for acute migraine headaches, similar to sumatriptan 50 mg or 100 mg. Addition of metoclopramide 10 mg improves relief of nausea and vomiting. Adverse events were mainly mild and transient, and were slightly more common with aspirin than placebo, but less common than with sumatriptan 100 mg.

Chlorpromazine for psychosis induced aggression or agitation  
1 Studie (n=30)
Overall the quality of evidence is limited, poor and dated. Where drugs that have been better evaluated are available, it may be best to avoid use of chlorpromazine. Where chlorpromazine is used for acute aggression or where choices are limited, relevant trials are possible and urgently needed.

Family therapy for anorexia nervosa 
13 Studien
There was some evidence (from two studies, 81 participants) to suggest that family therapy may be more effective than treatment as usual on rates of remission, in the short term (RR 3.83 95% CI 1.60 to 9.13). Based on one study (30 participants) there was no significant advantage for family therapy over educational interventions (RR 9.00 95% CI 0.53, 153.79) or over other psychological interventions (RR 1.13 95% CI 0.72 to 1.76) based on four studies (N=149).
All other reported comparisons for relapse rates, cognitive distortion, weight measures and dropouts yielded non-significant results.

Stroke liaison workers for stroke patients and carers: an individual patient data meta-analysis   
16 Studien (n=4.759)
There is no evidence for the effectiveness of this multifaceted intervention in improving outcomes for all groups of patients or carers. Patients with mild to moderate disability benefit from a reduction in death and disability. Patients and carers do report improved satisfaction with some aspects of service provision.

 

Aktivität


Simultaneous bilateral training for improving arm function after stroke 
18 Studien (n=549)
There is insufficient good quality evidence to make recommendations about the relative effect of simultaneous bilateral training compared to placebo, no intervention or usual care. We identified evidence that suggests that bilateral training may be no more (or less) effective than usual care or other upper limb interventions for performance in ADL, functional movement of the upper limb or motor impairment outcomes.

Exercise therapy for schizophrenia 
3 Studien
Results of this Cochrane review are similar to existing reviews that have examined the health benefits of exercise in this population (Faulkner 2005). Although studies included in this review are small and used various measures of physical and mental health, results indicated that regular exercise programmes are possible in this population, and that they can have healthful effects on both the physical and mental health and well-being of individuals with schizophrenia. Larger randomised studies are required before any definitive conclusions can be drawn.

Balance training (proprioceptive training) for patients with rheumatoid arthritis
Keine geeigneten Studien
There is no research available examining the efficacy of balance training alone in patients with rheumatoid arthritis. The effectiveness and safety of balance training to improve functional capacity of these patients remains unclear. We suggest that future research should give more importance to balance training by either increasing the number and duration of sessions or investigating its efficacy alone.´

 

Augen

 

Excimer laser refractive surgery versus phakic intraocular lenses for the correction of moderate to high myopia
3 RCTs
The results of this review suggest that phakic IOLs are safer than excimer laser surgical correction for moderate to high myopia in the range of -6.0 to -20.0 D and phakic IOLs are preferred by patients. While phakic IOLs might be accepted clinical practice for higher levels of myopia (greater than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism), it may be worth considering phakic IOL treatment over excimer laser correction for more moderate levels of myopia (less than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism). Further RCTs adequately powered for subgroup analysis are necessary to further elucidate the ideal range of myopia for phakic IOLs.

 

Chirurgie

 

Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults      
4 Studien (n=1.232)
There is evidence that laparoscopic fundoplication surgery is more effective than medical management for the treatment of GORD at least in the short to medium term. Surgery does carry some risk and whether the benefits of surgery are sustained in the long term remains uncertain. Treatment decisions for GORD should be based on patient and surgeon preference.

Interventions for the treatment of fractures of the mandibular condyle 
No high quality evidence is available in relation to this review question and no conclusions could be reached about the effectiveness or otherwise of the two interventions considered in this review. A need for further well designed randomised controlled trials exists. The trialists should account for all losses to follow-up and assess patient related outcomes. They should also report the direct and indirect costs associated with the interventions.

Miniport versus standard ports for laparoscopic cholecystectomy 
13 Studien (n=803)
Miniport laparoscopic cholecystectomy can be completed successfully in more than 85% of patients. Patients, in whom elective miniport laparoscopic cholecystectomy was completed successfully, had lower pain than those who underwent standard laparoscopic cholecystectomy. However, because of the lack of information on its safety, miniport laparoscopic cholecystectomy cannot be recommended outside well-designed, randomised clinical trials.

Surgical intervention for anorectal fistula  
10 RCTs
There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.
The use of Fibrin glue and advancement flaps are associated with low incontinence rates.
There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.

Staples versus sutures for closing leg wounds after vein graft harvesting for coronary artery bypass surgery. 
3 Studien (n=423)

These results suggest that there is no evidence of a difference in the risk of surgical site infection (SSI) and wound dehiscence when staples rather than sutures are used to close leg wounds after vein graft harvesting during CABG, however more research is needed.

Perianal injectable bulking agents as treatment for faecal incontinence in adults
4 Studien (n= 176)
A definitive conclusion cannot be drawn regarding the effectiveness of perianal injection of bulking agents for faecal incontinence due to the limited number of identified trials together with methodological weaknesses. Within the available data, however, we found no reliable evidence for effectiveness of one treatment over another in improving faecal incontinence. Larger well-designed trials with adequate numbers of subjects using reliable validated outcome measures are needed to allow definitive assessment of the treatment for both effectiveness and safety.

Joint lavage for osteoarthritis of the knee
7 Studien (n=567)
Joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function.

Covering ileo- or colostomy in anterior resection for rectal carcinoma  
6 RCTs
Covering stoma seems to be useful to prevent anastomotic leakage and urgent re-operations in patients receiving low anterior resection for rectal cancer. However, covering stoma does not seems to offer advantage in term of 30 days or long term mortality.

Embolisation therapy for pulmonary arteriovenous malformations  
Keine geeigneten Studien
Currently there are no randomised controlled trials to support or refute embolisation therapy for treatment of pulmonary arteriovenous malformations. However, randomised controlled trials are not always feasible on ethical grounds. Observational studies suggest that embolisation therapy reduces mortality and morbidity compared to no treatment in patients. A standardised approach to reporting with long-term follow up through registry studies can help to strengthen the evidence base for embolisation therapy in the absence of randomised controlled trials. Future viable randomised controlled trials may compare different embolisation devices against each other.

 

Frauen

 

Anti-TNF-treatment for pelvic pain associated with endometriosis   
1 Studie (n=21)
There is no enough evidence to support the use of anti-TNF-α drugs in the management of women with endometriosis for the relief of pelvic pain.

Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace
2 Studien (n=3.348)
When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Action cut-off lactate values need to consider the lactate meter used. Further studies may consider sub-group analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, future studies may address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period
10 Studien
More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.

Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome
7 Studien (n=690)
There is insufficient evidence to guide clinical practice on the benefits and harms of immediate delivery compared with expectant management for women with PPROM. To date all of the clinical trials have had methodological weaknesses and have been underpowered to detect meaningful measures of infant and maternal morbidity.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections   
4 Studien (n=1.361)
Vaginal preparation with povidone-iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery with ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone-iodine before performing cesarean deliveries.

5-FU for genital warts in non-immunocompromised individuals  
6 Studien (n=988)
The reviewed trials were highly variable in methods and quality, and the evidence provided by these studies was weak. Cure rates with several treatments were variable, and although 5-FU presents therapeutic results that are inferior to those seen with 5-FU + Inf α-2a (high dose) and 5-FU + CO2 Laser + Inf α-2a (high dose), the treatment should not be abandoned. Topical treatment with 5-FU has a therapeutic effect; however, the benefits and risks have not been determined clearly and further studies are needed.

High feedback versus low feedback of prenatal ultrasound for reducing maternal anxiety and improving maternal health behaviour in pregnancy  
4 Studien (n=365)
There is insufficient evidence to support either high or low feedback during a prenatal ultrasound to reduce maternal anxiety and promote health behaviour.

Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death 
38 Studien (n=3.679)
The use of vaginal misoprostol in the termination of second and third trimester of pregnancy is as effective as other prostaglandin preparations (including cervagem, prostaglandin E2 and prostaglandin F2alpha), and more effective than oral administration of misoprostol. However, important information regarding maternal safety, and in particular the occurrence of rare outcomes such as uterine rupture, remains limited. Future research efforts should be directed towards determining the optimal dose and frequency of administration, with particular attention to standardised reporting of all relevant outcomes and assessment of rare adverse events. Further information is required about the use of sublingual misoprostol in this setting.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation  
2 Studien (n=116)
The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.

Preconception lifestyle advice for people with subfertility  
No RCTs were located that assessed the effects of preconception advice on the chance of a live birth or other fertility outcomes in people who perceived that they may be infertile and were investigating the possibility of medical treatment to address subfertility. Given the lack of RCTs evaluating the effectiveness of preconception lifestyle advice for people in the afore-mentioned population, this review cannot provide guidance for clinical practice in this area. However, it does highlight the need for further research into this important subject.

Synchronised approach for intrauterine insemination in subfertile couples      
10 Studien
There is no evidence to advise one particular treatment option over another. The choice should be based on hospital facilities, convenience for the patient, medical staff, costs and drop-out levels. Since different time intervals between hCG and IUI did not result in different pregnancy rates, a more flexible approach might be allowed.

Ultrasound for fetal assessment in early pregnancy 
11 Studien (n=37.505)
Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

Human chorionic gonadotrophin for threatened miscarriage    
3 Studien (n=312)
The current evidence does not support the routine use of hCG in the treatment of threatened miscarriage.

 

Sucht

 

Reduction versus abrupt cessation in smokers who want to quit 
10 Studien (n=3.760)
Reducing cigarettes smoked before quit day and quitting abruptly, with no prior reduction, produced comparable quit rates, therefore patients can be given the choice to quit in either of these ways.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption 
50 Studien
Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

 

Schmerz

 

Combined chiropractic interventions for low-back pain 
12 Studien (n=2.887)
Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period
10 Studien (n=1.367)
More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.

Single dose oral codeine, as a single agent, for acute postoperative pain in adults      
35 Studien (n=2.478)
Single dose codeine 60 mg provides good analgesia to few individuals, and does not compare favourably with commonly used alternatives such as paracetamol, NSAIDs and their combinations with codeine, especially after dental surgery; the large difference between dental and other surgery was unexpected. Higher doses were not evaluated.

Single dose oral diflunisal for acute postoperative pain in adults 
9 Studien
Diflunisal has an analgesic effect similar to other NSAIDs in single dose, but benefits from providing significant analgesia for about twelve hours. This property may be useful when regular dosing is needed, or when taking several doses of a shorter acting analgesic is impractical.

Single dose oral gabapentin for established acute postoperative pain in adults
4 nicht publizierte Studien
Gabapentin 250 mg is statistically superior to placebo in the treatment of established acute postoperative pain, but the NNT of 11 for at least 50% pain relief over 6 hours with gabapentin 250 mg is of limited clinical value and inferior to commonly used analgesics. Gabapentin 250 mg is not clinically useful as a stand-alone analgesic in established acute postoperative pain, though this is probably the first demonstration of analgesic effect of an antiepileptic in established acute pain.

Triptans for acute cluster headache      
6 Studien
Zolmitriptan and sumatriptan are effective in the acute treatment of cluster headaches and may provide a useful treatment option, potentially offering convenience over oxygen therapy and a better safety and tolerability profile than ergotamine. Non-oral routes of administration are likely to provide better and more rapid responses.

Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults
There were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before such a judgement can be made.

 

Urologie

Auricular acupuncture for cocaine dependence   [Download PDF]Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men      
10 Studien (n=1.367)

 

Zahn 

Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus  
10 Studien (n = 250)
Conclusions are based on few small trials, with short follow-up, and judged to be at high risk of bias. Therefore conclusions should be viewed as preliminary and interpreted with great caution. It is still unclear when sinus lift procedures are needed. 5 mm short implants can be successfully loaded in maxillary bone with a residual height of 4 to 6 mm but their long-term prognosis is unknown. Elevating the sinus lining in presence of 1 to 5 mm of residual bone height without the addition of a bone graft may be sufficient to regenerate new bone to allow rehabilitation with implant-supported prostheses. Bone substitutes might be successfully used as replacements for autogenous bone. If the residual alveolar bone height is 3 to 6 mm a crestal approach to lift the sinus lining, to place 8 mm implants may lead to fewer complications than a lateral window approach, to place implants at least 10 mm long. There is no evidence that PRP treatment improves the clinical outcome of sinus lift procedures with autogenous bone or bone substitutes

Initial arch wires for alignment of crooked teeth with fixed orthodontic braces     
5 Studien (n = 517)
There is some evidence to suggest that there is no difference between the speed of tooth alignment or pain experienced by patients when using one initial aligning arch wire over another. However, in view of the general poor quality of the including trials, these results should be viewed with caution. Further RCTs are required.

Treatment of periodontal disease for glycaemic control in people with diabetes
7 Studien
There is some evidence of improvement in metabolic control in people with diabetes, after treating periodontal disease. There are few studies available and individually these lacked the power to detect a significant effect.
Improving periodontal health is an important objective in itself. However, in order to understand the potential of this treatment to improve glycaemic control among people with diabetes, larger, carefully conducted and reported studies are needed.

 

Diverses

 

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs     
27 Studien (n=11.398)
Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Organisational travel plans for improving health      
17 Studien
There is insufficient evidence to determine whether organisational travel plans are effective for improving health or changing travel mode.

Preventive staff-support interventions for health workers 
10 Studien (n=716)
There is insufficient evidence for the effectiveness of stress management training interventions to reduce job stress and prevent burnout among healthcare workers beyond the intervention period. Low quality evidence suggests that longer-term interventions with refresher or booster sessions may have more sustained positive effect, but this needs to be rigorously evaluated in further trials.
Low quality evidence exists to show that management interventions may improve some measures of job satisfaction. However, further trials are needed to assess whether this finding is replicable in other settings. There was insufficient evidence of the benefit of management interventions on staff absenteeism.

Interventions to improve question formulation in professional practice and self-directed learning
4 Studien
Evidence from our review suggests that interventions to increase the quality of questions formulated in practice produce mixed results at both short- (immediately following intervention), and moderate-term follow up (up to nine months), comparatively. Although three studies reported effectiveness estimates of an educational intervention for increasing the quality of question formulation within the short term, only one study examined the effectiveness in the longer term (one year) and revealed that search skills had eroded over time. Data suggests that sustainability of effects from educational interventions for question formulation are unknown.

Interventions for improving the adoption of shared decision making by healthcare professionals   
5 Studien
The results of this Cochrane review do not allow us to draw firm conclusions about the most effective types of intervention for increasing healthcare professionals' adoption of SDM. Healthcare professional training may be important, as may the implementation of patient-mediated interventions such as decision aids. Given the paucity of evidence, however, those motivated by the ethical impetus to increase SDM in clinical practice will need to weigh the costs and potential benefits of interventions. Subsequent research should involve well-designed studies with adequate power and procedures to minimise bias so that they may improve estimates of the effects of interventions on healthcare professionals' adoption of SDM. From a measurement perspective, consensus on how to assess professionals' adoption of SDM is desirable to facilitate cross-study comparisons. 

Glucocorticoids for the treatment of anaphylaxis  
Keine geeigneten Studien gefunden
We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.

Methotrexate monotherapy versus methotrexate combination therapy with non-biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis
19 Studien (n=2.025)
When the balance of efficacy and toxicity is taken into account, the moderate level of evidence from our systematic review showed no statistically significant advantage of the MTX combination versus monotherapy. Trials are needed that compare currently used MTX doses and combination therapies.

Enzyme replacement therapy for Anderson-Fabry disease  
5 Studien (n=187)
Five small, poor quality randomised controlled trials provide no robust evidence for use of either agalsidase alfa and beta to treat Anderson-Fabry disease.

Caffeine for the prevention of injuries and errors in shift workers 
13 Studien
Caffeine may be an effective intervention for improving performance in shift workers however, there are no trials from which we can assess its effect on injuries. The results largely originate from studies involving young participants under simulated conditions, and the extent to which the findings are generalisable to older workers and real world shift work is unclear. Based on the current evidence, there is no reason for healthy individuals who already use caffeine within recommended levels to improve their alertness to stop doing so. The assessment of the relative effects of caffeine to other potential countermeasures should be a focus of future research.

 

UPDATES

 

 

 

 

Akupunktur, Mai 2010:


Akupunktur ist eine ziemlich sichere Behandlung, mit ganz seltenen schweren Nebenwirkungen. Daher ist die Beantwortung der Frage hoch relevant, ob Akupunktur eine effektive Heilbehandlung ist oder nicht. Cochrane gibt dazu wesentliche Beiträge (mehr als 25 publizierte Übersichten, über 30 in Vorbereitung), die nun auf einer Webseite zusammengefasst sind.
Unter „Download PDF“ erhält man jeweils die Volltexte kostenfrei!

http://www.thecochranelibrary.com/details/collection/691705/Acupuncture-ancient-tradition-meets-modern-science.html

 

Thema

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Asthma Acupuncture for chronic asthma    [Download PDF
Augen Acupuncture for glaucoma  [Download PDF
Frauen Acupuncture and assisted conception  [Download PDF
  Acupuncture for induction of labour   [Download PDF
  Acupuncture for uterine fibroids  [Download PDF
Gastrointestinal Acupuncture for treatment of irritable bowel syndrome [Download PDF]
Kopfschmerz Acupuncture for migraine prophylaxis  [Download PDF]
  Acupuncture for tension-type headache  [Download PDF
Muskuloskeletal Acupuncture for neck disorders  [Download PDF]
  Acupuncture and dry-needling for low back pain [Download PDF]
  Acupuncture for lateral elbow pain [Download PDF
  Acupuncture for peripheral joint osteoarthritis [Download PDF
  Acupuncture and electroacupuncture
for the treatment of rheumatoid arthritis
 
[Download PDF
Nausea Acupuncture-point stimulation for chemotherapy-induced
nausea or vomiting 
 
[Download PDF
  Stimulation of the wrist acupuncture point P6 for
preventing postoperative nausea and vomiting
[Download PDF
Neurologie    

Acupuncture for Bell's palsy    

[Download PDF
  Acupuncture for epilepsy [Download PDF
  Acupuncture for restless legs syndrome  [Download PDF
  Acupuncture for vascular dementia  [Download PDF
  Acupuncture for stroke rehabilitation [Download PDF
  Acupuncture for dysphagia in acute stroke [Download PDF
  Acupuncture for acute stroke  [Download PDF
Psychische Erkrankungen Acupuncture for depression [Download PDF
  Acupuncture for schizophrenia  [Download PDF
Schlaf Acupuncture for insomnia [Download PDF]  
Sucht Acupuncture and related interventions for smoking cessation  [Download PDF
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Zuletzt verändert: 20.05.2010