Cochrane Db Syst Rev
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Cochrane Db Syst Rev · Jan 2000
ReviewCorticosteroids or ACTH for acute exacerbations in multiple sclerosis.
Corticosteroids are often used to improve the rate of recovery from acute exacerbation in multiple sclerosis (MS) patients. However, it is still unclear just how relatively effective these agents are and the type of drug, optimal dose, frequency, duration of treatment and route of administration are unknown. ⋯ We found evidence favouring the corticosteroid MP for acute exacerbation in MS patients. Data are insufficient to reliably estimate effect of corticosteroids on prevention of new exacerbations and reduction of long-term disability. Studies assessing long term risk/benefit and adverse effects of corticosteroids in MS patients are urgently needed.
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Cochrane Db Syst Rev · Jan 2000
ReviewThyroid hormone for preventing of neurodevelopmental impairment in preterm infants.
Observational studies have shown an association between transiently low thyroid hormone levels in preterm infants in the first weeks of life (transient hypothyroxemia) and an abnormal neurodevelopmental outcome. Thyroid hormone therapy might prevent this morbidity. ⋯ This review does not support the use of thyroid hormones in preterm infants to reduce neonatal mortality, improve neurodevelopmental outcome or to reduce the severity of respiratory distress syndrome. The a posteriori subgroup analyses of data from one study (van Wassenaer 1997) which showed benefits in infants 24-25 weeks gestation should be treated with caution. The small number of infants included in trials incorporated in this review limits the power of the meta-analysis to detect clinically important differences in neonatal outcomes. Future trials should be of sufficient size to detect clinically important differences in neurodevelopmental outcomes. They should consider enrolling those infants most likely to benefit from thyroid hormone treatment such as infants born at less than 27 weeks gestation and use thyroid hormones as treatment instead of prophylaxis.
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Maintenance of optimal lung function is an important therapeutic goal in cystic fibrosis as it is lung damage that, in the long term, is responsible for most premature death among affected people. Inhaled corticosteroids are being increasingly used to treat children and adults with cystic fibrosis. The rationale for their use is that they have the potential to reduce lung damage arising from inflammation. However chronic use of inhaled steroids may also have adverse effects. It is thus important to establish the current level of evidence about the potential benefits and harms of this practice. ⋯ Nine trials were identified reporting the use of inhaled steroids in 266 subjects aged between seven and 45 years with cystic fibrosis. Methodological quality was difficult to assess from published information, specifically with respect to concealment of allocation and method used to generate random sequence. Trials were heterogeneous with respect to inclusion criteria, specifically age, severity of pulmonary involvement, clinical diagnosis of asthma and pulmonary colonisation with Pseudomonas aeruginosa. Trials also differed in type and duration of treatment. Beclomethasone was given for periods of between four and 22 weeks in four trials, budesonide for six weeks and six months respectively in two, and fluticasone for periods of between six weeks and two years in the remaining three. Measures of the volume of air breathed out on a forcible expiration (forced expiratory volumes) were reported in most trials but these data could not be combined for this review partly because reports differed in the way data were summarised and partly because some data were not included in published reports. Outcomes of potentially greater relevance to affected individuals such as nutritional status or quality of life were not reported in any trial. Survival was not reported in any trial, but this may reflect the fact that maximum duration of follow up was too short to allow this outcome to be meaningfully assessed. Adverse effects were systematically documented in only two trials. Although one trial was halted prematurely because a proportion of all those taking part had acquired chronic lung infections with Pseudomonas aeruginosa, no conclusions can be reached from this one small trial as to whether this risk is increased as
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Cochrane Db Syst Rev · Jan 2000
ReviewOn-site mental health workers in primary care: effects on professional practice.
Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs). ⋯ This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.
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Research has highlighted the problems for carers of people with dementia. These include the effective loss of companionship and support of a life partner, social isolation and complex financial, legal and social decision making. The burden of caring is financially, emotionally and physically significant. Studies of the effects of ways of supporting carers and reducing the burden of caring often examine a range of outcomes. Probably because of these characteristics, no formal overview of this area of service provision has been undertaken. Moreover, the term 'intervention' in relation to caregivers of people with Alzheimer's disease is open to wide variations in interpretation at the level of service provision. Interventions range from the application of 'hi-tech' computer technology for socialy isolated carers, to the formation of specialist support groups and respite services. ⋯ With the limited nature of the research evidence in mind, it is not possible to recommend either wholesale investment in caregiver support programmes or withdrawal of the same. With the addition of further studies in future updates of this review, expected in early 1999, this presently inconclusive picture may become clearer. A number of conclusions relating to future areas of research can be put forward with more conviction. Specifically, 1) Future trials need to examine interventions included in the existing knowledge base on Alzheimer's carer-supportive interventions. 2) Outcome measures used should mirror those in similar studies. 3) Outcome measures need to be clinically and 'lay' relevant. 4) Trials need to be of longer duration given the 7-10 years median life expectancy of people with Alzheimer's Disease. 5) Sample sizes need to be increased and calculated properly given the likelihood of a moderate intervention effect (if any). 7) Blinding at the outcome assessment stage needs to be a part of future basic trial designs if bias is to be avoided. 8) If reviews are to have their power increased then quality o