Die 5 Minuten Evidenz - Cochrane Ausgabe 3/2010

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Ausgabe 3/2010 der Cochrane Library

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Herz, Kreislauf, CVD

Oxygen therapy for acute myocardical infarction
3 Studien (n=387)
There is no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute AMI. A definitive randomised controlled trial is urgently required given the mismatch between trial evidence suggestive of possible harm from routine oxygen use and recommendations for its use in clinical practice guidelines.

Promoting patient uptake and adherence in cardiac rehabilitation
10 Studien
There is some evidence to suggest that interventions to increase the uptake of cardiac rehabilitation can be effective. Few practice recommendations for increasing adherence to cardiac rehabilitation can be made at this time. Interventions targeting patient identified barriers may increase the likelihood of success. Further high quality research is needed.

Structured telephone support or telemonitoring programmes for patients with chronic heart failure
25 Studien (n> 9.000)
Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

Calcium channel blockers versus other classes of drugs for hypertension
18 Studien (n= 141.807)
Diuretics are preferred first-line over CCBs to optimize reduction of cardiovascular events. The review does not distinguish between CCBs, ACE inhibitors or ARBs, but does provide evidence supporting the use of CCBs over β-blockers. Many of the differences found in the current review are not robust and further trials might change the conclusions. More well-designed RCTs studying the mortality and morbidity of patients taking CCBs as compared with other antihypertensive drug classes are needed for patients with different stages of hypertension, different ages, and with different co-morbidities such as diabetes.

Hydralazine for essential hypertension
Keine geeigneten Studien
Hydralazine may reduce blood pressure when compared to placebo in patients with primary hypertension, however this data is based on before and after studies, not RCTs. Furthermore, its effect on clinical outcomes remains uncertain.

Spironolactone for hypertension
5 cross-over Studien
From the limited available evidence, spironolactone appears to lower blood pressure compared to placebo to a similar degree in patients with primary (essential) hypertension when doses of 100-500 mg/day are given. A dose of 25 mg/day did not statistically significantly reduce systolic or diastolic blood pressure, compared to placebo. Given the lack of a dose-response, coupled with a possible increased risk in adverse events with higher doses, doses of 25 to 100 mg/day are reasonable. There is no evidence of the effect of spironolactone on clinical outcomes in hypertensive patients.

Infektion

Interventions to improve disposal of human excreta for preventing diarrhoea
13 Studien (n= 33.400)
This review provides some evidence that interventions to improve excreta disposal are effective in preventing diarrhoeal disease. However, this conclusion is based primarily on the consistency of the evidence of beneficial effects. The quality of the evidence is generally poor and does not allow for quantification of any such effect. The wide range of estimates of the effects of the intervention may be due to clinical and methodological heterogeneity among the studies, as well as to other important differences, including exposure levels, types of interventions, and different degrees of observer and respondent bias. Rigorous studies in multiple settings are needed to clarify the potential effectiveness of excreta disposal on diarrhoea.

Teicoplanin versus vancomycin for proven or suspected infection
24 Studien (n=2610)
Teicoplanin and vancomycin are both effective in treating those with proven or suspected infection; however the incidence of adverse effects including nephrotoxicity was lower with teicoplanin. There were no cases of AKI needing dialysis. It remains unclear whether the differential effect on kidney function should influence which antibiotic be prescribed, although it may be reasonable to consider teicoplanin for patients at higher risk for AKI needing dialysis.

Lamivudine or adefovir dipivoxil alone or combined with immunoglobulin for preventing hepatitis B recurrence after liver transplantation
4 Studien (n= 136)
This review could not derive clear evidence from randomised clinical trials for the treatment of patients with chronic HBV following liver transplantation for preventing recurrence of HBV infection. Large randomised clinical trials comparing long-term combination treatment to each of the monotherapy alone, including the newer antiviral drugs, are needed.

Chemotherapy for second-stage Human African trypanosomiasis
9 Studien (n= 2577)
Choice of therapy for second stage Gambiense HAT will continue to be determined by what is locally available, but eflornithine and NECT are likely to replace melarsoprol, with careful parasite resistance monitoring. We need research on reducing adverse effects of currently used drugs, testing different regimens, and experimental and clinical studies of new compounds, effective for both stages of the disease.

Stavudine or zidovudine in three-drug combination therapy for initial treatment of HIV infection in antiretroviral-naïve individuals
9 Studien (n=2159)
While ideally future research would focus on direct comparison of standard therapeutic combinations of d4T+3TC+an NNRTI and AZT+3TC+an NNRTI to compare these regimens more directly, it is unlikely that additional trials will be mounted. Observational studies should focus on understanding outcomes, including toxicity and tolerability, in low- and middle-income countries.

Atmung

Glucocorticoid with cyclophosphamide for paraquat-induced lung fibrosis
3 Studien (n=164)
Based on the findings of three small RCTs of moderate to severely poisoned patients, glucocorticoid with cyclophosphamide in addition to standard care may be a beneficial treatment for patients with paraquat-induced lung fibrosis. To enable further study of the effects of glucocorticoid with cyclophosphamide for patients with moderate to severe paraquat poisoning, hospitals may provide this treatment as part of an RCT with allocation concealment.

Intravenous alpha-1 antitrypsin augmentation therapy for treating patients with alpha-1 antitrypsin deficiency and lung disease
2 Studien (n=140)
Augmentation therapy with alpha-1 antitrypsin cannot be recommended, in view of the lack of evidence of clinical benefit and the cost of treatment.

Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)
1 Studie (n= 14)
There is no current evidence to support or refute the routine use of aerosolized prostacyclin for patients with ALI and ARDS. There is an urgent need for more randomized clinical trials.

Kinder

Banked preterm versus banked term human milk to promote growth and development in very low birth weight infants
Keine geeigneten Studien
There are no randomised trials that compare preterm banked milk to banked term milk to promote growth and development in very low birth weight infants.

Prevention of diarrhoea in children with HIV infection or exposure to maternal HIV infection
6 Studien
Vitamin A shows benefits in reduction of mortality in HIV-infected children. The effect of vitamin A on children with HIV exposure is not clear and needs further review. Zinc and combination vitamin A, zinc and micronutrient supplementation did not show an effect compared to vitamin A alone in children with HIV infection. Cotrimoxazole reduced mortality and some morbidity in children with HIV infection. Further research may clarify the effects of these interventions on morbidity from diarrhoea and in the population of children with HIV exposure.

Urate oxidase for the prevention and treatment of tumor lysis syndrome in children with cancer
5 Studien (n=794)
Although urate oxidase might be effective in reducing serum uric acid, it is still unclear whether this translates into a reduction in mortality or renal failure. Clinicians should weigh the potential benefits of reducing uric acid and uncertain benefits of preventing renal failure or mortality from TLS against the potential risk of adverse effects.

Antihistamines used in addition to topical nasal steroids for intermittent and persistent allergic rhinitis in children
1 Studie (n=24)
In view of the lack of evidence for the benefit or lack of benefit of antihistamine add-on therapy with topical nasal steroids for children with intermittent or persistent allergic rhinitis, it is important that clinicians are mindful of the adverse effects of antihistamines and the additional costs that may be incurred.

Flow-cycled versus time-cycled synchronized ventilation for neonates
2 Studien (n=19)
There is insufficient evidence to determine the safety and efficacy of flow-cycled compared to time-cycled synchronized ventilation in neonates. Large randomized clinical trials using a parallel-group design and reporting on clinically important outcomes are warranted.

Non-surgical interventions for paediatric pes planus
3 Studien (n=305)
The evidence from randomised controlled trials is currently too limited to draw definitive conclusions about the use of non-surgical interventions for paediatric pes planus. Future high quality trials are warranted in this field. Only limited interventions commonly used in practice have been studied and there is much debate over the treatment of symptomatic and asymptomatic pes planus

Nutritional support in children and young people with cancer undergoing chemotherapy
8 Studien (n=159)
There is limited evidence from individual trials to suggest that parenteral nutrition is more effective than enteral nutrition in well-nourished children and young people with cancer undergoing chemotherapy. The evidence for other methods of nutritional support remains unclear. No studies were identified comparing the nutritional content in the PN or EN groups of studies. Further research, incorporating larger sample sizes and rigorous methodology utilising valid and reliable outcome measures, is essential.

Knochen

Bone morphogenetic protein (BMP) for fracture healing in adults
11 Studien
This review highlights a paucity of data on the use of BMP in fracture healing as well as considerable industry involvement in currently available evidence.There is limited evidence to suggest that BMP may be more effective than controls for acute tibial fracture healing, however, the use of BMP for treating nonunion remains unclear. The limited available economic evidence indicates that BMP treatment for acute open tibial fractures may be more favourable economically when used in patients with the most severe fractures.

Interventions for treating osteochondral defects of the talus in adults
1 Studie (n=15)
There is insufficient evidence from randomised trials to determine which interventions are best for osteochondral defects of the talus in adults. High quality randomised trials are required to guide non-surgical and surgical treatment decisions for these injuries.

Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults
3 Studien (n=174)
There is insufficient evidence from randomised controlled trials to determine when surgical treatment is indicated for acromioclavicular dislocation in adults in current practice. Sufficiently powered, good quality, well-reported randomised trials of currently-used surgical interventions versus conservative treatment for well-defined injuries are required.

Krebs

Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases
2 Studien (n= 358)
Given the unclear risk of bias in the included studies, the results of this analysis have to be interpreted with caution. Analysis of all included patients, SRS plus WBRT, did not show a survival benefit over WBRT alone. However, performance status and local control were significantly better in the SRS plus WBRT group. Furthermore, significantly longer OS was reported in the combined treatment group for RPA Class I patients as well as patients with single metastasis.

Neurologie/Psychiatrie

Creatine for amyotrophic lateral sclerosis/motor neuron disease
3 Studien (n= 386)
In patients already diagnosed with clinically probable or definite amyotrophic lateral sclerosis (ALS), creatine at doses ranging from 5 to 10 g per day did not have a statistically significant effect on survival, ALS functional rating revised scores (ALSFRS-R) progression or percent predicted forced vital capacity (FVC) progression.

Daclizumab for relapsing remitting multiple sclerosis
Keine geeigneten Studien
Although studies examining daclizumab for relapsing remitting multiple sclerosis were located, methodologic limitations resulted in the exclusion of all studies. Some of the studies were labelled as crossover trials, however they only compared the effect of different interventions for the same individual. The true randomized crossover trial should compare the effect of different groups, which receive the same intervention, only with the difference in sequence. In other words, the crossover comparison should be between the different groups, rather than on the individual between pretreatment and post treatment. At the same time, all the individuals should be randomly allocated to different groups. There was also a rigorous randomized controlled trial, but the follow-up was shorter than one year (only 44 weeks). In general, daclizumab is safe and well tolerated in combination of interferon treated multiple sclerosis population. Improvements in methodology in future studies are required for meaningful synthesis of data.

Interventions for sensory impairment in the upper limb after stroke
13 Studien (n = 467)
Multiple interventions for upper limb sensory impairment after stroke are described but there is insufficient evidence to support or refute their effectiveness in improving sensory impairment, upper limb function, or participants' functional status and participation. There is a need for more well-designed, better reported studies of sensory rehabilitation.

Circuit class therapy for improving mobility after stroke
6 Studien (n = 292)
CCT is safe and effective in improving mobility for people after moderate stroke and may reduce inpatient length of stay. Further research is required, investigating quality of life, participation and cost-benefits, that compares CCT to standard care and that also investigates the differential effects of stroke severity, latency and age.

Meditation therapies for attention-deficit/hyperactivity disorder (ADHD)
4 Studien (n= 183)
As a result of the limited number of included studies, the small sample sizes and the high risk of bias, we are unable to draw any conclusions regarding the effectiveness of meditation therapy for ADHD. The adverse effects of meditation have not been reported. More trials are needed.

Psychological interventions for antisocial personality disorder
11 Studien (n= 471)
Results suggest that there is insufficient trial evidence to justify using any psychological intervention for adults withAsPD. Disappointingly few of the included studies addressed the primary outcomes defined in this review (aggression, reconviction, global functioning, social functioning, adverse effects). Three interventions (contingency management with standard maintenance; CBT with standard maintenance; 'Driving Whilst Intoxicated program' with incarceration) appeared effective, compared to the control condition, in terms of improvement in at least one outcome in at least one study. Each of these interventions had been originally developed for people with substance misuse problems. Significant improvements were mainly confined to outcomes related to substance misuse. No study reported significant change in any specific antisocial behaviour. Further research is urgently needed for this prevalent and costly condition.

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)
4 Studien
There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

Evaluation of the efficacy and safety of adjuvant treatment to levodopa therapy in Parkinson s disease patients with motor complications
44 Studien (n= 8.436)
Compared to placebo, adjuvant therapy reduces off-time, levodopa dose, and improves UPDRS scores in PD patients who develop motor complications on levodopa therapy. However, this is at the expense of increased dyskinesia and numerous other side-effects. Indirect comparisons suggest that dopamine agonist therapy may be more effective than COMTI and MAOBI therapy, which have comparable efficacy. However, as indirect comparisons should be interpreted with caution, direct head-to-head randomised trials assessing the impact of these different drug classes on overall patient-rated quality of life are needed.

Music therapy for acquired brain injury
7 Studien (n= 184)
RAS may be beneficial for gait improvement in people with stroke. These results are encouraging, but more RCTs are needed before recommendations can be made for clinical practice. More research is needed to examine the effects of music therapy on other outcomes in people with ABI.

Pharmacological interventions for antisocial personality disorder
8 Studien (n= 394)
The body of evidence summarised in this review is insufficient to allow any conclusion to be drawn about the use of pharmacological interventions in the treatment of antisocial personality disorder.

Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD)
7 Studien (n= 271)
There is no evidence of effect of SSRIs in children and emerging evidence of harm. There is limited evidence of the effectiveness of SSRIs in adults from small studies in which risk of bias is unclear.

Statins for the treatment of dementia
3 Studien (n= 748)
There is insufficient evidence to recommend statins for the treatment of dementia. Analysis from the studies available, including one large RCT, indicate statins have no benefit on the outcome measures ADAS-Cog or MMSE. We need to await full results from CLASP 2008 before we can be certain. This Cochrane review will be updated as these results become available.

Aktivität

Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica
10 Studien
Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed; patients with sciatica experience little or no difference between the two approaches. Low quality evidence suggests little or no difference between those who received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact onthe estimate of effect and is likely to change our confidence in it.

Exercise interventions for upper-limb dysfunction due to breast cancer treatment
24 Studien (n= 2132)
Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer. In the post-operative period, consideration should be given to early implementation of exercises, although this approach may need to be carefully weighed against the potential for increases in wound drainage volume and duration. High quality research studies that closely monitor exercise prescription factors (e.g. intensity), and address persistent upper-limb dysfunction are needed.

Augen

Intravitreal low molecular weight heparin and 5-Fluorouracil for the prevention of proliferative vitreoretinopathy following retinal reattachment surgery
2 Studien (n= 789)

Chirurgie

Human growth hormone and glutamine for patients with short bowel syndrome
5 Studien
The results suggest a positive effect of human growth hormone on weight gain and energy absorption. However, in the majority of trials, the effects are short-lived returning to baseline shortly after cessation of therapy. The temporary benefit calls into question the clinical utility of this treatment. To date, the evidence is inconclusive to recommend this therapy. Consideration should be made to studying patients during the active phase of intestinal adaptation rather than in the setting of chronic intestinal failure. The role of HGH in paediatric short bowel syndrome remains unknown.

Incision and drainage of perianal abscess with or without treatment of anal fistula
6 Studien (n= 479)
The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.

Orthodontics for treating temporomandibular joint (TMJ) disorders
Keine geeigneten Studien
There are insufficient research data on which to base our clinical practice on the relationship of active orthodontic intervention and TMD. There is an urgent need for high quality randomised controlled trials in this area of orthodontic practice.
When considering consent for patients it is essential to reflect the seemingly random development/alleviation of TMD signs and symptoms.

Surgery for tympanic membrane retraction pockets
2 Studien (n= 71)
No evidence currently exists to either support or refute the role of surgery in the management of tympanic membrane retractions. Higher quality studies are much needed to ascertain this.

Frauen

Anticoagulant therapy for deep vein thrombosis (DVT) in pregnancy
Keine geeigneten Studien
There is no evidence from randomised controlled trials on the effectiveness of anticoagulation for deep vein thrombosis in pregnancy.Further studies are required.

Copper containing intra-uterine devices versus depot progestogens for contraception
2 Studien
In the populations studied, the IUD was more effective than hormonal contraception with respect to pregnancy prevention. High quality research is urgently needed to compare the effects, if any, of these two commonly used contraception methods on HIV acquisition/seroconversion and HIV/AIDS disease progression.

Cytoreductive surgery plus chemotherapy versus chemotherapy alone for recurrent epithelial ovarian cancer
Keine geeignetenStudien
We found no evidence from RCTs to inform decisions about secondary surgical cytoreduction and chemotherapy compared to chemotherapy alone for women with recurrent epithelial ovarian cancer. Ideally, a large randomised controlled trial or, at the very least, well designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances are needed to compare these treatment modalities.

DNA-repair pathway inhibitors for the treatment of ovarian cancer
Keine geeignetenStudien
There are to date no published RCT data on the effectiveness and side effects of DNA-repair pathways inhibitors used alone or in association with conventional chemotherapy in the treatment of ovarian cancer. On-going trials have been identified and results are awaited and will be included in future updates of this review.

Maternal position during caesarean section for preventing maternal and neonatal complications
17 Studien (n= 683)
There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. Larger studies are needed.

Perioperative enhanced recovery programmes for gynaecological cancer patients
Keine geeigneten Studien
We currently have no evidence from high quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed.

Repeat digital cervical assessment in pregnancy for identifying women at risk of preterm labour
2 Studien (n= 7163)
We found no evidence to support the use of RDCA in pregnancy to reduce the prevalence of preterm birth. We have found insufficient evidence to assess adverse effects of the intervention.

Techniques of intrauterine fetal transfusion for women with red-cell isoimmunisation for improving health outcomes
2 Studien (n= 44)
There is little available high quality information from randomised controlled trials to inform the optimal procedural technique when performing fetal intrauterine fetal blood transfusions for women with an anaemic fetus due to red cell alloimmunisation. Further research evaluating the benefits and harms associated with different techniques is required.

Active versus expectant management for women in the third stage of labour
5 Studien (n= 6486)
Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population, but adverse effects are identified. Women should be given information on the benefits and harms to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third stage management. Data are also required from low-income countries.

Adherence compounds in embryo transfer media for assisted reproductive technologies
16 Studien (n= 3698)
There is evidence of an improved clinical pregnancy rate with the use of adherence compounds in ART cycles but no evidence of an effect on live birth rate. The increase in multiple pregnancy rate may be the result of the use of a combination of an adherence compound and a policy of transferring more than one embryo. Further studies of adherence compounds with single embryo transfer need to be undertaken.

High dose rate versus low dose rate intracavity brachytherapy for locally advanced uterine cervix cancer
4 Studien (n= 1265)
This review showed no significant differences between HDR- and LDR-ICBT when considering OS, DSS, RFS, local control rate, recurrence, metastasis and treatment related complications for women with cervical carcinoma. Due to some potential advantages of HDR-ICBT (rigid immobilization, outpatient treatment, patient convenience, accuracy of source and applicator positioning, individualized treatment) we recommend the use of HDR-ICBT for all clinical stages of cervix cancer.

Hormonal contraceptives for contraception in overweight or obese women
11 Studien (n= 39.531)
Body weight addresses overall body size, while BMI generally reflects the amount of fat. Only one of three studies using BMI found a higher pregnancy risk for overweight women. The efficacy of implants and injectable contraceptives may be unaffected by body mass. The field could use trials of contraceptive methods with groups stratified by BMI. The current evidence on effectiveness by BMI is limited. However, the contraceptive methods examined here are still among the most effective when the recommended regimen is followed.

Interventions for clinical and subclinical hypothyroidism in pregnancy
3 Studien (n=3140)
Levothyroxine treatment of clinical hypothyroidism in pregnancy is already standard practice given the documented benefits from earlier non-randomised studies. Whether levothyroxine should be utilised in autoimmune and subclinical hypothyroidism remains to be seen, but it may prove worthwhile, given a possible reduction in preterm birth and miscarriage.
Selenomethionine as an intervention in women with thyroid autoantibodies is promising, particularly in reducing postpartum thyroiditis. There is a probable low incidence of adverse outcomes from levothyroxine and selenomethionine. High-quality evidence is lacking and large-scale randomised trials are urgently needed in this area. Until evidence for or against universal screening becomes available, targeted thyroid function testing in pregnancy should be implemented in women at risk of thyroid disease and levothyroxine utilised in hypothyroid women.

Palliative surgery versus medical management for bowel obstruction in ovarian cancer
1 Studie (n=47)
We found only low quality evidence comparing palliative surgery and medical management for bowel obstruction in ovarian cancer. Therefore we are unable to reach definite conclusions about the relative benefits and harms of the two forms of treatment, or to identify sub-groups of women who are likely to benefit from one treatment or the other. However, there is weak evidence in support of surgical management to prolong survival.

Screening and subsequent management for gestational diabetes for improving maternal and infant health
4 Studien (n=3972)
There was insufficient evidence to determine if screening for gestational diabetes, or what types of screening, can improve maternal and infant health outcomes.

Tranexamic acid for preventing postpartum haemorrhage
2 Studien
Tranexamic acid decreases postpartum blood loss after vaginal birth and after caesarean section based on two RCTs of unclear quality which reported on only a few outcomes. Further investigations are needed on efficacy and safety of this regimen for preventing PPH.

Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia
4 Studien (n=415)
Although strong evidence supports the use of magnesium sulphate for prevention and treatment of eclampsia, trials comparing alternative treatment regimens are too small for reliable conclusions.

Cervical preparation for second trimester dilation and evacuation
Cervical preparation with osmotic dilators and/or misoprostol before second-trimester D&E is safe and effective. Osmotic dilators appear to provide superior cervical dilation when compared to prostaglandins alone or when combined with prostaglandins, however this difference in cervical dilation does not appear to result in differences in procedure time or complication rates. There does not appear to be clear clinical benefit from two days of cervical preparation compared to one-day prior to second-trimester D&E below 19 weeks gestational duration. Mifepristone plus misoprostol was associated with high rates of pre-procedural expulsions and does not appear to be a useful method of cervical preparation before second-trimester dilation and evacuation. Same-day procedures appear to be a safe and reasonable option in the early second trimester, however, more research is needed to assess the effectiveness and safety of same-day procedures in the later second trimester.

Different methods for the induction of labour in outpatient settings
28 Studien (n=2616)
Induction of labour in outpatient settings appears feasible. We do not have sufficient evidence to know which induction methods are preferred by women, or the interventions that are most effective and safe to use in outpatient settings.

Interventions for preventing mastitis after childbirth
5 Studien (n= 960)
There was insufficient evidence to show effectiveness of any of the interventions, including breastfeeding education, pharmacological treatments and alternative therapies, regarding the occurrence of mastitis or breastfeeding exclusivity and duration. While studies reported the incidence of mastitis, they all used different interventions. Caution needs to be applied when considering the findings of this review as the conclusion is based on studies, often with small sample sizes. An urgent need for further adequately powered research is needed into this area to conclusively determine the effectiveness of these interventions.

Timing of prophylactic uterotonics for the third stage of labour after vaginal birth
3 Studien (n= 1671)
Administration of oxytocin before and after the expulsion of placenta did not have any significant influence on many clinically important outcomes such as the incidence of postpartum haemorrhage, rate of placental retention and the length of the third stage of labour. However, the number of available studies were limited. The only uterotonic drug used was oxytocin, mainly through intravenous infusion, therefore its extrapolation to other routes of administration should be interpreted cautiously. More studies are required to examine other maternal and neonatal outcomes using consistent approaches.

Haut

Interventions for cellulitis and erysipelas
25 Studien (n= 2488)
We cannot define the best treatment for cellulitis and most recommendations are made on single trials. There is a need for trials to evaluate the efficacy of oral antibiotics against intravenous antibiotics in the community setting as there are service implications for cost and comfort.

Interventions for preventing occupational irritant hand dermatitis
4 Studien (n= 894)
Although the findings of this review were generally positive, no statistical significance was reached. We conclude that at present there is insufficient evidence for the effectiveness of most of the interventions used in the primary prevention of OIHD. This does not mean that current measures are necessarily ineffective, as the limited studies to date have been rather small and of poor quality. Larger well designed RCTs are now needed in different workplaces to establish the effectiveness of various preventative strategies.

Interventions for melasma
20 Studien (n= 2125)
The quality of studies evaluating melasma treatments was generally poor and available treatments inadequate. High-quality randomised controlled trials on well-defined participants with long-term outcomes to determine the duration of response are needed.

Sucht

Interventions for smoking cessation and reduction in individuals with schizophrenia
21 Studien
Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardising their mental state. Bupropion may also reduce the amount these patients smoke. CR may help this group of patients to quit and reduce smoking. We failed to find convincing evidence that other interventions have a beneficial effect on smoking behaviour in schizophrenia.

Schmerz

Topical NSAIDs for acute pain in adults
47 Studien (n= 3455)
Topical NSAIDs can provide good levels of pain relief, without the systemic adverse events associated with oral NSAIDs, when used to treat acute musculoskeletal conditions.

Zahn

Interventions for the management of external root resorption 
Keine geeigneten Studien
We were unable to identify any reports of randomised controlled trials regarding the efficacy of different interventions for the management of external root resorption. In view of the lack of any high level evidence on this topic, it is suggested that clinicians decide on the most appropriate means of managing this condition according to their clinical experience with regard to patient related factors. Future research should consist of robust clinical trials which conform to the CONSORT statement (www.consort-statement.org/).

Hypnosis for children undergoing dental treatment    
3 Studien (n = 69)
Although there are a considerable number of anecdotal accounts indicating the benefits of using hypnosis in paediatric dentistry, on the basis of the three studies meeting the inclusion criteria for this review there is not yet enough evidence to suggest its beneficial effects.

Diverses

Parent training support for intellectually disabled parents  
3 Studien
There is some risk of bias in the included studies, with limited information available to assess possible bias and to fully assess the findings of one included study. Whilst the evidence presented here does seem promising with regard to the ability of such interventions to improve parenting knowledge and skill in this population, there is a need for larger RCTs of interventions before conclusions can be drawn about the effectiveness of parent training for this group of parents.

Pharmacological interventions for the prevention of allergic and febrile non-haemolytic transfusion reactions   
3 Studien
None of the three studies found that medication prior to transfusion reduces NHTR. This applied regardless of the patient's history of NHTR and the use of leukodepleted blood products in the transfusion. However, this conclusion is based on three trials of moderate to low quality. A better-powered RCT is necessary to evaluate the role of pretransfusion medication in the prevention of NHTR. Inclusion criteria should be restricted to patients at high risk of developing NHTR, with no restriction by age, history of transfusion reactions and type of blood products (leukodepleted or not).

Sapropterin dihydrochloride for phenylketonuria
2 Studien (n= 153)
There is evidence of short-term benefit from using sapropterin in some patients with sapropterin-responsive forms of phenylketonuria; blood phenylalanine concentration is lowered and protein tolerance increased. There are no serious adverse events associated with using sapropterin in the short term.
There is no evidence on the long-term effects of sapropterin and no clear evidence of effectiveness in severe phenylketonuria.

Functional capacity evaluations for the prevention of occupational re-injuries in injured workers
1 Studie (n= 372)
There is no evidence for or against the effectiveness of FCE compared to no intervention. A short version of FCE showed similar effectiveness to a long version in preventing re-injury. More RCTs are needed.

Lactulose versus Polyethylene Glycol for Chronic Constipation
10 Studien
Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation.

Deferasirox for managing transfusional iron overload in people with sickle cell disease
1 Studie (n= 203)
Deferasirox appears to be as effective as deferoxamine. However, only limited evidence is available assessing the efficacy regarding patient-important outcomes. The short-term safety of deferasirox seems to be acceptable, however, follow-up was too short to exclude long-term side effects and thus treatment with deferasirox cannot be judged completely safe. Future studies should assess long-term outcomes for safety and efficacy, and also evaluate rarer adverse effects.

Gene therapy for sickle cell disease
Keine geeigneten Studien
No randomised or quasi-randomised clinical trials of gene therapy for sickle cell disease were reported. Thus, no objective conclusions or recommendations in practice can be made on gene therapy for sickle cell disease. This systematic review has identified the need for well-designed, randomised controlled trials to assess the benefits and risks of gene therapy for sickle cell disease.

Outreach strategies for expanding health insurance coverage in children      
2 Studien (n= 480)
The two studies included in this review provide evidence that in the US providing health insurance information and application assistance, and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.

Pharmaceutical policies: effects of restrictions on reimbursement 
29 Studien
Implementing restrictions to coverage and reimbursement of selected medications can decrease third-party drug spending without increasing the use of other health services (6 studies). Relaxing reimbursement rules for drugs used for secondary prevention can also remove barriers to access. Policy design, however, needs to be based on research quantifying the harm and benefit profiles of target and alternative drugs to avoid unwanted health system and health effects. Health impact evaluation should be conducted where drugs are not interchangeable. Impacts on health equity, relating to the fair and just distribution of health benefits in society (sustainable access to publically financed drug benefits for seniors and low income populations, for example), also require explicit measurement. 
 

UPDATES

• Absorbable suture materials for primary repair of episiotomy and second degree tears 
• Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children 
• Antibiotics to reduce post-tonsillectomy morbidity  
• Arthroplasties (with and without bone cement) for proximal femoral fractures in adults  
• Azathioprine or 6-mercaptopurine for induction of remission in Crohn's disease 
• Behavioural treatment for chronic low-back pain  
• Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome  
• Concurrent chemoradiotherapy in non-small cell lung cancer 
• Drug therapy for the management of cancer-related fatigue  
• Immediate postabortal insertion of intrauterine devices   
• Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) and acute lung injury in children and adults 
• Intravenous immunoglobulin for Guillain-Barré syndrome 
• Interventions for preoperative smoking cessation 
• Multinutrient fortification of human breast milk for preterm infants following hospital discharge 
• Therapeutic ultrasound for venous leg ulcers  
• Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis   
• Weight reduction for non-alcoholic fatty liver disease  
• Workload and surgeonés speciality for outcome after colorectal cancer surgery