Diabetes Treatments

Type 2 diabetes: culturally tailored education can improve blood sugar control Can diet alone control type 2 diabetes? No evidence yet …

The Cochrane Library
the best single source of reliable evidence
about the effects of health care

Strictly Embargoed until 00:01 hours BST, 16th July 2008

This alert highlights some of the key health care conclusions and their
implications for practice as published next week in The Cochrane Library,
2008, Issue 3

To receive a full copy of the reviews highlighted in this newsletter, or to
arrange an interview with an author, please contact Jennifer Beal on 44
01243 770633 / 44 0 7802 468863 or by email, jbeal@wileycom

Reviews highlighted in this newsletter:

Regular salmeterol for asthma: more evidence of long-term problems
People with asthma who regularly use salmeterol are at a greater risk of
non-fatal adverse events than those using placebos This conclusion was
arrived at by a team of Cochrane Researchers who drew together data from
26 trials involving 62,630 patients

Foot pain: custom-made insoles offer relief
Custom-made insoles known as foot orthoses can reduce foot pain caused by
arthritis, overly prominent big toe joints and
highly arched feet, a new
systematic review shows

After ankle surgery: mobilise with care
People recover faster after surgery for ankle fracture if they are given
a cast or splint that can be removed to let them exercise the ankle, than
if their foot is placed in an immobilising plaster cast If the fracture
is stable, then encouraging them to walk soon after surgery is also
beneficial However, increased activity does increase the chance of
experiencing problems with the surgical wound

Childhood diarrhoea: treat with zinc over six months of age
Zinc supplementation benefits children suffering from diarrhoea in
developing countries, but only in infants over six months old, Cochrane
Researchers have found Their study supports World Health Organization
WHO guidelines for treatment of diarrhoea with zinc, although not in
the very young

Combating urinary schistosomiasis: both metrifonate and praziquantel can
be used
In 2000 the World Health Organization WHO stopped recommending
metrifonate for treating urinary schistosomiasis because the drug did not
appear to be as effective as the treatment of choice, praziquantel Now
a
systematic review published in the latest edition of The Cochrane
Library indicates that both metrifonate and praziquantel are effective at
treating the infection

Type 2 diabetes: culturally tailored education can improve blood sugar
control
Using community-based health advocates, delivering information within
same-gender groups or adapting dietary and lifestyle advice to fit a
particular communitys likely diet can help people with type 2 diabetes
control their blood sugar levels, certainly for up to six months,
following health education

Can diet alone control type 2 diabetes? No evidence yet
Despite strong evidence that type 2 diabetes can be prevented or at least
delayed by a combination of lifestyle changes and good dietary advice, a
team of Cochrane Researchers found that there is no indication whether
dietary advice alone can prevent the disease

Chronic fatigue patients benefit from cognitive behaviour therapy
Cognitive behaviour therapy is effective in treating the symptoms of
chronic fatigue syndrome, according to a recent systematic review carried
out by Cochrane Researchers

A selection of other new or updated
Cochrane Reviews

Regular salmeterol for asthma: more evidence of long-term problems

People with asthma who regularly use salmeterol are at a greater risk of
non-fatal serious adverse events than those using placebos This
conclusion was arrived at by a team of Cochrane Researchers who drew
together data from 26 trials involving 62,630 patients

The researchers found that over a four to six month period, for every
thousand people treated for asthma there were 45 who suffered a serious
adverse event on regular salmeterol, compared to only 40 if a placebo
inhaler was given

Salmeterol is a long-acting beta2-agonist It is inhaled by people with
asthma twice daily, and relieves symptoms for up to 12 hours It is
generally recommended for use along with corticosteroid inhalers also
known as preventer inhalers

Over the last decade some researchers and practitioners have expressed
anxieties that although salmeterol can relieve asthma symptoms, it could
cause long-term problems

We found that the biggest increase in risk was seen in people with asthma
who were not taking inhaled corticosteroids; however, there is no guarantee
that inhaled corticosteroids abolish the risk all
together, says lead
researcher Christopher Cates who works in Community Health Sciences at St
Georges, London, UK

The authors recommend that people should follow the manufacturers advice
not to increase the dose of salmeterol during an exacerbation Furthermore
regular salmeterol should not be used as an alternative to inhaled
corticosteroids Benefits and risks both need to be considered before
embarking on long term treatment with regular salmeterol

Work is currently in progress on a similar assessment of formoterol
another long-acting beta2-agonist

Cates CJ, Cates MJ Regular treatment with salmeterol for chronic asthma:
serious adverse events Cochrane Database of Systematic Reviews 2008, Issue
3 Art No: CD006363 DOI: 101002/14651858CD006363pub2 Cochrane
Airways Group

SEE WWWCOCHRANEORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS
REVIEW, AVAILABLE FROM WEDNESDAY 16th JULY 2008

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Foot pain: custom-made insoles offer relief

Custom-made insoles known as foot orthoses can reduce foot pain caused by
arthritis, overly prominent big toe joints and highly arched feet, a
new
systematic review shows

A team of Cochrane Researchers found that custom orthoses were safe
interventions for foot pain in a number of different conditions However,
more research is required to develop an in depth understanding of their
effectiveness

Approximately one in four people are affected by foot pain at any given
time It is often disabling and can impair mood, behaviour, self-care
ability and overall quality of life People suffer from foot pain for a
variety of reasons, but pain is more common in the elderly and those with
chronic conditions such as arthritis In the majority of cases, patients
undergo a combination of different treatments, one of which may be custom-
made foot orthoses insoles moulded to a cast of the foot

The Cochrane Systematic Review focuses on the results of 11 trials that
together involved 1,332 people Researchers found that custom foot
orthoses can relieve pain within three months in adults with rheumatoid
arthritis, as well as in children with juvenile idiopathic arthritis, an
early onset form of the disease Adults with painful highly arched feet or
painfully prominent big toe joints also benefited from treatment with
orthoses over three
and six month periods respectively

Custom foot orthoses can be an effective treatment for a variety of
conditions, but there are still many causes of foot pain for which the
benefit of this treatment is unclear There is also a lack of data on the
long term effects of treating with orthoses, says Fiona Hawke, the lead
researcher, who works at the Central Coast campus of the University of
Newcastle, Australia

Hawke F, Burns J, Radford JA, du Toit V Custom-made foot orthoses for the
treatment of foot pain Cochrane Database of Systematic Reviews 2008, Issue
3 Art No: CD006801 DOI: 101002/14651858CD006801pub2 Cochrane
Musculoskeletal Group

SEE WWWCOCHRANEORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS
REVIEW, AVAILABLE FROM WEDNESDAY 16th JULY 2008

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After ankle surgery: mobilise with care

People recover faster after surgery for ankle fracture if they are given a
cast or splint that can be removed to let them exercise the ankle, than if
their foot is placed in an immobilising plaster cast If the fracture is
stable, then encouraging them to walk soon after surgery is also
beneficial
However, increased activity does increase the chance of
experiencing problems with the surgical wound These conclusions are
published in a systematic review included in the latest update of The
Cochrane Library

Ankle fracture is one of the most common fractures of the lower limb,
especially in young men and older women In about half of the cases, the
broken bone requires surgery to realign the bones, and then the lower leg
and foot are placed in a cast to immobilise and protect the area

The problem with immobilisation is that it can lead to pain, stiffness,
weakness and swelling in the ankle A team of Cochrane Researchers
therefore looked to see whether there was evidence that using removable
casts or splints can improve outcome

The researchers found only limited evidence, but current research indicated
that removable casts or splints which allow the ankle to be exercised soon
after surgery reduced pain and increased mobility when compared to using a
traditional plaster cast But early exercise on the ankle also led to
increased albeit mainly minor adverse events, such as problems with the
surgical wound and changes in skin sensation

Getting a patient to exercise soon after
surgery has significant benefits,
but the increased risks to the wound show that you need to make sure that a
person can do this safely before supplying them with a removable cast or
splint instead of a standard cast, says Christine Lin, who works at the
Musculoskeletal Division of The George Institute for International Health,
Australia

Lin CWC, Moseley AM, Refshauge KM Rehabilitation for ankle fractures in
adults Cochrane Database of Systematic Reviews 2008, Issue 3 Art No:
CD005595 DOI: 101002/14651858CD005595pub2 Cochrane Bone, Joint and
Muscle Trauma Group

SEE WWWCOCHRANEORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS
REVIEW, AVAILABLE FROM WEDNESDAY 16th JULY 2008

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Childhood diarrhoea: treat with zinc over six months of age

Zinc supplementation benefits children suffering from diarrhoea in
developing countries, but only in infants over six months old, Cochrane
Researchers have found Their study supports World Health Organization
WHO guidelines for the treatment of diarrhoea with zinc, although not in
the very young

Zinc is clearly of benefit to children with diarrhoea,
says lead
researcher Marzia Lazzerini, who works at the Unit of Research on Health
Services and International Health in Trieste, Italy

Diarrhoea is a common cause of death for children in the developing world,
occurring most often in children aged between six months and five years It
is estimated that two million children die every year as a result of the
disease Zinc is a micronutrient that plays a critical role in physical
growth as well as in gastrointestinal and immune function Its main
dietary sources are red meat, fish and dairy products, but these are costly
and in short supply in many developing countries Currently the WHO
advises treating a child with zinc for between 10 and 14 days, as well as
giving oral rehydration salts to reduce the risk of death due to
dehydration

The Cochrane Researchers identified 18 trials of zinc treatment that
together involved 6,165 people from Asia, South America and Africa
Collectively the trials show that zinc is effective in reducing the
duration of diarrhoea in children aged between six months and five years
Below six months, two large trials involving 1,334 children, in three
continents found no effect

These studies back up previous
research that shows zinc can play an
important role in restoring children with diarrhoea to full health No
conclusions regarding zincs impact on hospitalisation or death could be
drawn form the trials, but given these results its expected that a policy
of zinc supplementation during diarrhoea in the community could also reduce
hospitalisation rate and mortality, says Lazzerini

Lazzerini M, Ronfani L Oral zinc for treating diarrhoea in children
Cochrane Database of Systematic Reviews 2008, Issue 3 Art No: CD005436
DOI: 101002/14651858CD005436pub2 Cochrane Infectious Diseases Group

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Combating urinary schistosomiasis: both metrifonate and praziquantel can be
used

In 2000 the World Health Organization WHO stopped recommending
metrifonate for treating urinary schistosomiasis because the drug did not
appear to be as effective as the treatment of choice, praziquantel Now a
systematic review published in the latest edition of The Cochrane Library
indicates that both metrifonate and praziquantel are effective at treating
the infection The team of researchers who carried out this study suggest
that
metrifonate may be a valid addition to the current one-drug strategy
against urinary schistosomiasis

These findings were reached after considering the data in 24 trials that
together involved 6,315 participants

Urinary schistosomiasis occurs when a tiny worm, a blood fluke Schistosoma
haematobium, penetrates a persons skin while walking or bathing in fresh
water contaminated with snails that contain the worm The fluke lays eggs
in the body, and these eggs cause tissue damage that leads to blood in
urine and pain on passing urine If left untreated they can cause serious
disease including kidney failure Estimates indicate that more than 100
million people in African and Eastern Mediterranean regions are infected by
the flukes, resulting in considerable social and economic hardships

Praziquantel requires only one dose and is operationally more convenient,
while metrifonate requires three at 14-day intervals This could be a
strong reason for stopping metrifonate use, especially in rural community-
based treatment programmes, where it is difficult to give multiple doses
However, the researchers believe that it would be prudent to have more than
one drug in use in order to
minimise the chance of the organism developing
resistance against the only drug, praziquantel

Relying only on praziquantel for treating schistosomiasis is a risky
strategy as it could encourage the development of drug resistance, says
lead researcher Anthony Danso-Appiah, who works at the Liverpool School of
Tropical Medicine, Liverpool, UK

Danso-Appiah A, Utzinger J, Liu J, Olliaro P Drugs for treating urinary
schistosomiasis Cochrane Database of Systematic Reviews 2008, Issue 3
Art No: CD000053 DOI: 101002/14651858CD000053pub2 Cochrane
Infectious Diseases Group

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Type 2 diabetes: culturally tailored education can improve blood sugar
control

Using community-based health advocates, delivering information within same-
gender groups or adapting dietary and lifestyle advice to fit a particular
communitys likely diet can help people with type 2 diabetes control their
blood sugar levels, certainly for up to six months, following health
education This conclusion was reached by a team of Cochrane Researchers
after they considered the data in 11 trials that involved 1,603 people

Type 2 diabetes is a
particular problem for minority ethnic groups who
originate from developing countries, but live in upper-middle income or
high income countries These people tend to have low socio-economic status
and find that they are faced with many physical, communication and cultural
barriers that make it difficult to access healthcare effectively

The Cochrane Researchers found 11 trials where people had deliberately
tried to overcome cultural barriers In short-term studies, culturally
appropriate health education programs led to improved blood-sugar control
within 3 months This benefit was still seen when the 6-month trial
periods ended Knowledge about diabetes and healthy lifestyles also
improved over this time period One-year later, however, the benefits had
not been sustained

These are important and encouraging results They show that providing
culturally tailored information can help people control their diabetes
says Kamila Hawthorne, who works at the Department of Primary Care and
Public Health at the University of Cardiff, UK

Diabetes is a chronic condition and complications can develop over many
years We now need to carry out longer term studies with larger groups, all
measuring
the same results, to discover which type of assistance is most
useful and see how to keep the benefits running for longer, says Hawthorne

Hawthorne K, Robles Y, Cannings-John R, Edwards AGK Culturally appropriate
health education for type 2 diabetes mellitus in ethnic minority groups
Cochrane Database of Systematic Reviews 2008, Issue 3 Art No: CD006424
DOI: 101002/14651858CD006424pub2 Cochrane Metabolic and Endocrine
Disorders Group

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Can diet alone control type 2 diabetes? No evidence yet

Despite strong evidence that type 2 diabetes can be prevented or at least
delayed by a combination of lifestyle changes and good dietary advice, a
team of Cochrane Researchers found that there is no indication whether
dietary advice alone can prevent the disease

Type 2 diabetes is very common and the number of people affected is
increasing The disease is linked to obesity, with 80 of individuals who
develop the disease being obese Therefore as the incidence of obesity
rises around the world, so too does the incidence of type 2 diabetes The
World Health Organization WHO estimates that more than 180 million
people
worldwide have diabetes It claims that this number is likely to more than
double by 2030

When a team of Cochrane Researchers set out to see if dietary advice alone
could help a person with type 2 diabetes, they were only able to identify
two trials that together involved just 358 people

Considering the importance of this disorder, we were disappointed to find
such a small amount of relevant data, says lead researcher Lucie Nield,
who works in Centre for Food, Physical Activity Obesity, University of
Teesside, Middlesbrough

The two studies did, however, indicate that dietary advice alone could play
an important role One study randomly assigned people to either a control
group or a dietary advice group After six years 677 of people in the
control group had diabetes, compared with only 438 in the advice group
This was a 33 reduction In another study 12 months of dietary advice led
to significant reductions in many diabetes related factors, such as insulin
resistance, fasting C-peptide, fasting proinsulin, fasting blood glucose,
fasting triglycerides, and fasting cholesterol and PAI-1

These two studies give grounds for believing that dietary advice alone
could play an
important role in reducing type 2 diabetes, but we do need
more well-designed, long-term studies before we can work out the best
advice to give, says Nield

http://wwwwhoint/mediacentre/factsheets/fs312/en/

Nield L, Summerbell CD, Hooper L, Whittaker V, Moore H Dietary advice for
the prevention of type 2 diabetes mellitus in adults Cochrane Database of
Systematic Reviews 2008, Issue 3 Art No: CD005102 DOI:
101002/14651858CD005102pub2 Cochrane Metabolic and Endocrine Disorders
Group

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Chronic fatigue patients benefit from cognitive behaviour therapy

Cognitive behaviour therapy is effective in treating the symptoms of
chronic fatigue syndrome, according to a recent systematic review carried
out by Cochrane Researchers

Chronic fatigue syndrome CFS is a potentially long-lasting illness that
can cause considerable distress and disability Some estimates suggest it
may affect as many as 1 in 100 of the population globally There is no
widely accepted explanation for the disease and patients are currently
offered a variety of different treatments Cognitive behaviour therapy
CBT uses psychological
techniques to balance negative thoughts that may
impair recovery with more realistic alternatives In treating CFS, these
techniques are combined with a gradual increase in activity levels

The researchers looked at data from 15 studies involving a total of 1,043
patients with CFS The studies compared the effects of CBT with those of
usual care and other psychological therapies and suggest that in both cases
CBT is more effective at reducing the severity of symptoms, provided
patients persist with treatment

Further research is required to determine whether CBT is more beneficial
than other forms of treatment, such as exercise and relaxation therapies
The researchers also suggest that CBT could be more effective if used as
part of a combination treatment approach

CFS is a challenging illness for patients, and there is ongoing
controversy about its causes There remain unanswered questions, but the
available evidence is clear - CBT can help many people with CFS, says lead
researcher Jonathan Price, who works at the University of Oxford in the UK

Price JR, Mitchell E, Tidy E, Hunot V Cognitive behaviour therapy for
chronic fatigue syndrome in adults Cochrane Database of
Systematic Reviews
2008, Issue 3 Art No: CD001027 DOI: 101002/14651858CD001027pub2
Cochrane Depression, Anxiety and Neurosis Group

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Extracts from a selection of other Cochrane Systematic Reviews

This section contains extracts from 11 selected new or updated reviews also
publishing in The Cochrane Library 2008, Issue 3 These extracts have been
divided into headings of:
Respiratory
Pain
Psychological
Policy
Internal
Disease
Cancer
Smoking

To receive a full copy of the results from this selection, or to arrange an
interview with an author, contact Jennifer Beal on 44 01243 770633 / 44
0 7802 468863 or by email, jbeal@wileycom

Respiratory

Combination fluticasone and salmeterol versus fixed dose combination
budesonide and formoterol for chronic asthma in adults and children
CD004106 by Lasserson et al
Background
Combination therapies are frequently recommended as maintenance therapy for
people with asthma, whose disease is not adequately controlled with inhaled
steroids Fluticasone/salmeterol FP/SAL and budesonide/formoterol BUD/F
have been assessed against their respective monocomponents,
but there is a
need to compare these two therapies on a head-to-head basis
Extract from the Implications for Practice findings
The confidence intervals for our estimates in our primary outcomes include
no statistically significant difference However, the width of the
confidence intervals for these endpoints also include possibly meaningful
differences between the treatments in either direction and as such more
evidence would help to improve their precision Serious adverse events were
too infrequent to generate findings which could be easily interpreted Our
analyses could not detect significant differences between these drugs in
terms of lung function and symptoms These observations pertain to adults
and adolescents whose asthma is not adequately controlled with high doses
of inhaled steroids

Intranasal corticosteroids for nasal airway obstruction in children with
moderate to severe adenoidal hypertrophy
CD006286 by Zhang et al
Background
Adenoidal hypertrophy is generally considered a common condition of
childhood When obstructive sleep apnoea or cardio-respiratory syndrome
occurs, adenoidectomy is generally indicated In less severe cases, non-
surgical interventions may be
considered, however few medical alternatives
are currently available Intranasal steroids may be used to reduce nasal
airway obstruction
Extract from the Implications for Practice findings
Limited evidence suggests that intranasal corticosteroids may significantly
improve nasal obstruction symptoms in children with moderate to severe
adenoidal hypertrophy and that this improvement may be associated with a
reduction in adenoid size Given the potential clinically relevant benefits
and relatively good tolerability of intranasal corticosteroids, these drugs
may be indicated as an alternative treatment for children with moderate to
severe adenoidal hypertrophy when adenoidectomy is not urgently required or
not available

Non-invasive positive pressure ventilation CPAP or bilevel NPPV for
cardiogenic pulmonary edema
CD005351 by Vital et al
Background
Non-invasive positivepressure ventilation NPPV has been widely used to
alleviate signs and symptoms of respiratory distress due to cardiogenic
pulmonary edema NPPV prevents alveolar collapse and helps redistribute
intra-alveolar fluid, improving pulmonary compliance and reducing the
pressure of breathing
Extract from the Implications for
Practice findings
Data from RCTs have demonstrated that NPPV CPAP and bilevel NPPV is
effective in reducing hospital mortality, intubation rate and ICU length of
stay In addition, NPPV resulted in faster improvement and was better
tolerated than standard medical care Further, our meta-analysis did not
demonstrate an increase in the incidence of adverse events or AMI during
and after NPPV application CPAP should be considered as first option in
the choosing of NPPV because the evidence for bilevel NPPV remains
inconclusive due to insufficient patient numbers recruited to the studies
to detect statistical power to define its effectiveness

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Pain

Normobaric and hyperbaric oxygen therapy for migraine and cluster
headache
CD005219 by Bennett et al
Background
Migraine and cluster headaches are severe and disabling Migraine affects
up to 18 of women, while cluster headaches are much less common 02 of
the population A number of acute and prophylactic therapies are
available Hyperbaric oxygen therapy HBOT is the therapeutic
administration of 100 oxygen at environmental pressures greater than one
atmosphere, while
normobaric oxygen therapy NBOT is oxygen administered
at one atmosphere
Extract from the Implications for Practice findings
While there is some evidence that HBOT may effectively terminate migraine
headache in a general population of migraineurs, the practical problems
involved in delivery of therapy suggest that HBOT should be reserved for
those migraineurs resistant to standard pharmacological therapies There
is, however, insufficient evidence of the efficacy of HBOT in this subgroup
of patients to recommend HBOT as a routine therapy HBOT cannot be
recommended as a prophylactic therapy for migraine There is no evidence to
support the practice of administering NBOT to patients with acute
migrainous headache

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Psychological

Psychosocial interventions for prevention of psychological disorders in
law enforcement officers
CD005601 by Peñalba et al
Background
Psychosocial interventions are widely used for the prevention of
psychological disorders in law enforcement officers
Extract from the Implications for Practice findings
There is insufficient evidence to show whether police officers benefit
from
psychosocial interventions including exercise-based interventions There is
lack of evidence that psychosocial interventions can reduce stress-related
psychological symptoms

Cannabis and schizophrenia
CD004837 by Rathbone et al
Background
Many people with schizophrenia use cannabis and its effects on the illness
are unclear
Extract from the Implications for Practice findings
1 For people with schizophrenia - At present, the data is too limited to
support, or refute, the use of cannabis/cannabinoid compounds for people
suffering with schizophrenia
2 For clinicians - There is insufficient trial-based evidence to support
or refute the use of cannabis based interventions Clearly the clinician
cannot be sure that treating patients with cannabis/cannabinoid compounds
is desirable practice It is understandable if clinicians, and people with
schizophrenia, felt that treatment outside of a randomised controlled trial
would be difficult to justify
3 For policy makers - There is an absence of robust data regarding the
clinical implications of using cannabis based compounds in schizophrenia

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Policy

Printed
educational materials: effects on professional practice and health
care outcomes
CD004398 by Farmer et al
Background
Printed educational materials PEMs are widely used passive dissemination
strategies to improve knowledge, awareness, attitudes, skills, professional
practice and patient outcomes Traditionally they are presented in paper
formats such as monographs, publication in peer-reviewed journals and
clinical guidelines and appear to be the most frequently adopted method for
disseminating information
Extract from the Implications for Practice findings
PEMs are a commonly used method of disseminating information to healthcare
professionals They can be distributed to large numbers of healthcare
professionals and are relatively cheap Studies of the effects of PEMs
generally show small improvements in the process of care Only a few
studies have evaluated the effects of PEMs and have generally shown small
deteriorations of uncertain clinical significance However these studies
tend to be small and methodologically weak Further there is little
evidence about how to optimize educational materials Those interested in
using PEMs should be aware of the potentially small effects and
limitations
of the current evidence

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Internal

Open surgical procedures for incisional hernias
CD006438 by den Hartog et al
Background
Incisional hernias occur frequently after abdominal surgery and can cause
serious complications The choice of a type of open operative repair is
controversial Determining the type of open operative repair is
controversial, as the recurrence rate may be as high as 54
Extract from the Implications for Practice findings
There is good evidence from three trials included in this review that open
mesh repair is superior to suture repair in terms of recurrences, but
inferior in the occurrence of wound infection There is insufficient
evidence from five trials in this review as to which type of mesh or which
position of the mesh on- or sublay should be used in open ventral hernia
repair Also, insufficient evidence was found to advocate the use of the
components separation technique

Interventions for renal vasculitis in adults
CD003232 by Walters et al
Background
Renal vasculitis presents as rapidly progressive glomerulonephritis RPGN
which comprises of a group of conditions
characterised by acute kidney
failure AKF, haematuria and proteinuria Treatment of these conditions
comprises steroid and non-steroid agents in combination with plasma
exchange in several situations Although immunosuppression overall has been
very successful in treatment of these conditions, many questions remain
unanswered in terms of dose and duration of therapy and the use of plasma
exchange
Extract from the Implications for Practice findings
Plasma exchange is effective in patients with severe ARF secondary to
vasculitis On current data, the use of pulse CPA results in an increased
risk of relapse when compared to continuous use but a reduced total dose
The use of cotrimoxazole is likely to be beneficial to prevent relapse of
vasculitis AZA is effective as maintenance therapy once remission has been
achieved

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Disease

Interventions for skin changes caused by nerve damage in leprosy
CD004833 by Reinar et al
Background
More than three million persons are disabled by leprosy worldwide The main
complication of sensory nerve damage is neuropathic ulceration,
particularly of the feet In this review we
explored interventions that can
prevent and treat secondary damage to skin and limbs
Extract from the Implications for Practice findings
Which of the interventions are the most effective? Topical ketanserin may
be more effective than clioquinol cream or zinc paste and topical phenytoin
may be more effective than saline dressing in ulcer healing However, this
is based on very weak evidence, for topical ketanserin only one study
tested the comparison and for phenytoin the summary analysis of two studies
did not show a very clear effect For the other comparisons the results
were equivocal

Vaccines for post-exposure prophylaxis against varicella chickenpox in
children and adults
CD001833 by Macartney and McIntyre
Background
Live attenuated varicella vaccines for the prevention of varicella
chickenpox has been demonstrated both in randomised controlled trials
RCTs and in population-based immunisation programmes in countries such as
the United States However, many countries do not routinely immunise
children against varicella, and exposures continue to occur Although the
disease is often mild, complications such as secondary bacterial infection,
pneumonitis and encephalitis occur in
about 1 of cases, usually leading to
hospitalisation The use of varicella vaccine in persons who have recently
been exposed to the varicella zoster virus has been studied as a form of
post-exposure prophylaxis PEP
Extract from the Implications for Practice findings
This review provides information relevant to immunisation policy makers
Although routine childhood varicella vaccination has been provided through
publicly funded immunisation programmes in a few countries such as the USA,
Canada, and Australia Macartney 2005; MMWR 1996; NACI 2004 experience
indicates that VZV circulation persists, despite moderately high vaccine
coverage, and the risk of exposure of unimmunised individuals to those with
varicella also persists The findings of this review are particularly
applicable to young children in the household or other close contact
settings However safety data are not available

Probiotics for induction of remission in Crohns disease
CD006634 by Butterworth et al
Background
Crohns disease has a high morbidity and there is no known cure Current
treatments have multiple side effects and an effective treatment with
minimal side effects is desired Probiotics have been proposed as
such a
treatment but their efficacy is undetermined There is some evidence that
probiotics are effective in other conditions affecting the gastrointestinal
tract and they are popular with patients They are thought to work through
competitive action with commensal and pathogenic flora, influencing the
immune response
Extract from the Implications for Practice findings
There is currently no evidence to support the use of probiotics for the
induction of remission in Crohns disease The use of probiotics as
induction therapy for Crohns disease cannot be recommended at this time

Budesonide for induction of remission in Crohns disease
CD000296 by Seow et al
Background
Corticosteroids play a key role in the induction of remission in Crohns
disease However, corticosteroids can cause significant adverse events
Budesonide is an alternate enteral glucocorticoid with limited systemic
bioavailability
Extract from the Implications for Practice findings
Budesonide is more effective than placebo or mesalamine for induction of
remission in active ileo-caecal Crohns disease Although short-term
efficacy with budesonide is less than with conventional steroids,
particularly in patients with severe
disease or more extensive colonic
involvement, the likelihood of adverse events and adrenal suppression is
lower

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Cancer

Fraction size in radiation treatment for breast conservation in early
breast cancer
CD003860 by James et al
Background
Shortening the duration of radiation therapy would benefit women with early
breast cancer treated with breast conservation It may also improve access
to radiation therapy by improving efficiency in radiation oncology
departments globally This can only happen if the shorter treatment is as
effective and safe as conventional radiation therapy
Extract from the Implications for Practice findings
In selected women with early breast cancer node negative tumours with
negative margins and size 5 cm or less shortened fractionation regimens
may be considered

Chemotherapeutic wafers for High Grade Glioma
CD007294 by Hart et al
Background
Standard treatment for high grade glioma HGG usually entails biopsy or
surgical resection where possible followed by radiotherapy Systemic
chemotherapy is usually only given in selected cases and its use is often
limited by side effects
Implanting wafers impregnated with chemotherapy
agents into the resection cavity represents a novel means of delivering
drugs to the central nervous system CNS with fewer side effects It is
not clear how effective this modality is or whether it should be
recommended as part of standard care for HGG
Extract from the Implications for Practice findings
There is evidence that Gliadel increases survival in primary therapy for
GBM but not for recurrent disease, and that this benefit is without a
significant increase in adverse events There is no evidence of enhanced
PFS or QOL These findings are based predominantly on two well designed
trials with a total of just under 300 patients In a well selected subgroup
of patients presenting with presumed GBM, Gliadel warrants consideration
for use as primary therapy Decisions on the use of Gliadel need to be made
on an individual basis as part of a multi-disciplinary team discussion

[To top]

Smoking

Nicotine receptor partial agonists for smoking cessation
CD006103 by Cahill et al
Background
Nicotine receptor partial agonists may help people to stop smoking by a
combination of
maintaining moderate levels of dopamine to counteract
withdrawal symptoms acting as an agonist and reducing smoking
satisfaction acting as an antagonist Varenicline was developed as a
nicotine receptor partial agonist from cytisine, a drug widely used in
central and Eastern Europe for smoking cessation The first trial reports
of varenicline were released in 2006, and further trials have now been
published or are currently are underway
Extract from the Implications for Practice findings
Varenicline increased the chances of successful long-term smoking
cessation by between two- and three-fold compared with pharmacologically
unassisted quit attempts
More people quit successfully with varenicline than with bupropion
One open-label trial of varenicline versus nicotine replacement therapy
demonstrated a modest benefit of varenicline
The effectiveness of varenicline as an aid to relapse prevention has not
been clearly established
The main adverse effect of varenicline was nausea, but mostly at mild to
moderate levels and tending to subside over time
Possible links with serious adverse events, including depressed mood,
agitation and suicidal thoughts, are
currently under review

[To top]

- Ends -

Notes for editors

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Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, et al
Methodology and reports of systematic Reviews and meta-analysies: a
comparison of Cochrane Reviews with articles published in paper-based
journal