The Cochrane Library newsletter, 2005, issue 2
The best single source of reliable evidence about the effects of health care
Psychological interventions can help fight fat
People who are overweight or obese can use behavioural and cognitive-behavioural strategies to help lose weight.
Social, cultural and dietary factors have all led to a rapid increase in the number of people who are clinically overweight or obese. But there are major gaps in our understanding of the ways that diet, exercise and psychological therapies can help an individual lose weight.
The Cochrane Review Authors therefore looked at data from 36 trials that involved 3,495 adult participants. The trials employed a variety of different psychological interventions. People, who want to loose weight benefit from behavioural and cognitive behavioural interventions which are aimed to help people take control of food stimuli, reinforce good behaviour, develop methods of self-monitoring and problem solving, as well as learning to set realistic goals for themselves.
The authors concluded that, when combined with dietary and exercise strategies, behavioural and cognitive behaviour therapy can help a person lose weight.
"This work should encourage people to look more seriously at these techniques, and perform some research that studies long-term outcome," says lead author Dr Kelly Shaw who works in the Department of Health and Human Services in Hobart, Australia.
Review title: Shaw et al: Psychological interventions for overweight or obesity. The Cochrane Database of Systematic Reviews 2005 Issue 2.
Chest physio doesn't help infants with bronchiolitis
Chest physiotherapy using vibration and percussion techniques does not reduce length of hospital stay, oxygen requirements, or reduce symptoms in infants with acute bronchiolitis who are not being ventilated and don't have any other accompanying illness.
Bronchiolitis is a viral infection of the airways in the lungs, and is a major cause of medical emergencies during winter in children under two years of age. Tackling this disease makes heavy use of healthcare resources.
The standard treatment involves making sure the child has enough oxygen, fluid and food, and possibly using bronchiodilators and steroids.
In addition, some doctors have tried using a variety of different methods of chest physiotherapy to help clear secretions from the trachea and bronchial passages in the lungs.
Other doctors, however, worry that this may cause additional suffering without bringing substantial benefit.
Drawing data from three studies (two from the UK, one from Argentina) the Cochrane Review Authors concluded that they could not recommend chest physiotherapy using either percussion or vibration techniques for use with these children.
"It would be interesting to study the effects of using chest physiotherapy in an outpatient situation," says lead author Dr Carla Perrotta, who works at the Centre of Epidemiology Research at the National Academy of Medicine, Buenos Aires, Argentina.
Review title: Perrotta et al: Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. The Cochrane Database of Systematic Reviews 2005 Issue 2.
Oxygenation is improved in hospitalised neonates when they are positioned on their fronts
Positioning babies with respiratory distress on their front increases oxygenation. This is particularly so in preterm ventilated infants. But these children must have cardio respiratory monitoring.
Due to the realisation that positioning babies on their backs reduced the general incidence of sudden infant death, doctors and nurses have tended to position all babies on their backs.
Some specialists, however, have reported that babies with respiratory distress go to sleep more readily when held upright over a person's shoulder. If laid down babies and young children seem to try to turn themselves over and lie on their fronts.
Looking at the data from 21 studies, Cochrane Review Authors found evidence that positioning infants on their fronts (prone) increased oxygenation. As most of the studies involved premature infants who were being supported on ventilators, they suggest that this finding may be most appropriate to this group of children.
They also add a note of warning. "Although placing infants and children in the prone position may improve respiratory function, the association of sudden infant death with prone positioning means that infants should only be placed in this position if continuous cardio respiratory monitoring is used," says lead author Deborah Wells who works at The Children's Hospital at Westmead, in NSW Australia.
Review title: Wells et al: Positioning for acute respiratory disease in hospitalised infants and children. The Cochrane Database of Systematic Reviews 2005 Issue 2.
Don't take HRT if the sole reason is to ward off cardiovascular disease
Doctors should not recommend that post-menopausal women start hormone replacement therapy (HRT) just to prevent cardiovascular events. Also, women at particular risk of blood clots should be discouraged from using HRT to prevent cardiovascular events.
Post-menopausal women are at higher risk of cardiovascular disease (CVD) than younger women. There are sound biological arguments why giving post-menopausal women extra oestrogen might protect them from CVD, and various uncontrolled studies appear to confirm this idea. However, the question of whether HRT has a long-term benefit for women at risk of CVD is unresolved.
To answer this, Cochrane Review Authors drew on data from 10 large, well run studies. Pooling the results they were able to compare the effects of giving HRT to 12,353 women, with giving placebos to 11,930 other women.
They concluded that giving HRT does not protect post-menopausal women from CVD. In addition, women who have specific risks that may make them prone to suffer from blood clots should be discouraged from taking HRT at all.
Review title: Gabriel Sánchez et al: Hormone replacement therapy for preventing cardiovascular disease in post-menopausal women. The Cochrane Database of Systematic Reviews 2005 Issue 2.
NSAIDs don't increase bleeding after tonsillectomy in children
You can give children NSAIDs for pain relief after removing their tonsils because there is no evidence that the drugs significantly increase bleeding
Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are used to reduce pain after children have had their tonsils removed. But NSAIDs can reduce the ability of blood platelets to stick together and initiate a blood clot. Consequently there is some concern that using NSAIDs leaves the wound more prone to bleeding.
By looking at 13 trials that involved 955 children, the Cochrane Review Authors concluded that NSAIDs did not significantly alter the number of children who bled so much after the operation that they needed to return to surgery for surgeons to stop it.
Also, fewer children experienced nausea and vomiting if they were given NSAIDs as part of their treatment regime.
"There is no evidence to support withholding NSAIDs for paediatric tonsillectomy," says lead reviewer Dr Mary Carwell, a consultant anaesthetist at North Manchester General Hospital.
Review title: Cardwell et al: Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. The Cochrane Database of Systematic Reviews 2005 Issue 2.
Memantine provides some help in moderate to severe Alzheimer's disease
The low affinity glutamate NMDA receptor antagonist memantine can slightly reduce deterioration in patients with moderate to severe Alzheimer's disease, but the effect in less severely affected people is unknown.
Alzheimer's disease is found in over 50% of people with dementia at autopsy. It is the commonest single cause of dementia affecting some 2% of people aged 65 with the prevalence doubling every five years to at least 90 years of age. As more is understood about the disease, drugs have been introduced that aim to enhance nerve activity in the brain.
One option is to target the part of central nervous system activity driven by the neurotransmitter L-glutamate. This amino acid plays a key role in normal brain function, especially the formation and reinforcement of memories. In Alzheimer's disease, nerve cells can become overactive to the point where they die. Consequently there is the hope that memantine, which blocks some of L-glutamate's receptors, may reduce symptoms of dementia.
Cochrane Review Authors concluded that, compared to placebo, giving 20 mg/day memantine reduced symptoms in people with moderate to severe Alzheimer disease. After six months, patients given memantine had slightly less functional and cognitive deterioration and were less likely to have become agitated. However, for patients who had already developed agitation, evidence of any effect of the drug was absent. It was impossible to say anything definite about whether memantine is useful in less severe Alzheimer's disease.
The reviewers also looked to see if memantine could help people with vascular dementia. Although it seemed to help reduce cognitive deterioration, the effect was not big enough to be apparent to the doctors treating the patients, and was possibly more short-lived than in Alzheimer's disease.
In both diseases memantine was well tolerated with few recorded adverse events.
Rupert McShane, one of the co-authors said: "This is the only treatment licensed for more severe Alzheimer's disease, so there is little doubt that it is a useful advance. The problem is that its effect is small. And we're worried that one of the most important studies has still not been published. This sort of delay usually means that the results were not so good, and if that study found a very different result from the others it could change our conclusions."
"Whether the drug is good enough for health services to buy is a moot point. The National Institute for Clinical Excellence in the UK has suggested that it might not be, but there's not much data to go on and there's no doubt that if we really want to know whether it's cost-effective we need to do a larger and longer randomised trial measuring quality of life in a way which everyone can agree is sensible. Unfortunately, when effective drugs are not publicly funded it inevitably creates a two-tier service because only those who can afford to pay privately can be prescribed the drug," says McShane.
Review title: Areosa Sastre et al: Memantine for dementia. The Cochrane Database of Systematic Reviews 2005 Issue 2.
A programme of music therapy can help people with schizophrenia
When added to standard care, music therapy helps people with schizophrenia improve their global state, mental state and social functioning.
Using musical experiences and the relationships that develop through them can be a dynamic force for change. Since the 1950s therapists have claimed that this means of communication and expression can help people with serious mental illness develop relationships and address issues they can't cope with using words alone.
To assess whether there is strong evidence to support this claim, a tam of Cochrane Review Authors looked at four studies that met their stringent inclusion criteria. Each study compared standard care with standard care augmented by music therapy. The studies looked for differences in outcome 1-3 months after treatment. The number of sessions that patients went to ranged from 7.5 to 78.
In all four studies, patients receiving music therapy did better than those getting standard care alone.
The Cochrane authors say that the specific techniques of music therapy, which include musical improvisation and discussion of personal issues related to the musical process, require specialised training for the therapist. But there is no need for the client to have any particular musical ability or prior experience.
The effects of music therapy seemed to be strongly linked to the number of therapy sessions. "In order to benefit from music therapy, a person needs to participate in regular sessions over a few months," says Dr Christian Gold who works in the Faculty of Health Studies at Sogn og Fjordane University College, Sandane, Norway.
Review title: Gold et al: Music therapy for schizophrenia or schizophrenia-like illnesses. The Cochrane Database of Systematic Reviews 2005 Issue 2.
Most electric brushes no better than manual toothbrushes
A review of 42 trials has shown that in most cases manual toothbrushes remove as much plaque as their expensive electronic counterparts, and protect just as well against inflamed gums. In fact, the only type of electric toothbrush more effective than a manual brush is that with a rotating-oscillating head.
The review, led by Professor Peter Robinson of the University of Sheffield, found that only brushes with circular heads that move a quarter turn in one direction and then back a quarter turn, clean better than a traditional toothbrush.
These results show that many people may be wasting money on toothbrushes they believe will clean their teeth better, when actually a much cheaper traditional brush would do the job just as well. For the best possible cleaning performance consumers should opt for an electric brush with a rotating-oscillating head.
Sales of electric toothbrushes are rising in the UK. In 1999 they accounted for two per cent of all sales, and by 2001 this figure had increased to seven per cent. There are a range of different types of electric toothbrushes available – including those that move bristles with ultrasound, and those where the head either moves side to side or round and round, as well as those with rotating oscillating heads.
Professor Robinson explains, "People with electric toothbrushes that don't have rotating-oscillating heads shouldn't worry, as it won't be doing them any harm. However, if they bought an electric toothbrush to get their teeth as clean as possible then it is worth investing in a brush with a rotating-oscillating head.
"Toothbrush choice is as much about personal preference as anything else, and people tend to take affordability, availability and professional recommendation into account. However, it is important that consumers know how well their toothbrush will work before making a choice."
Review title: Robinson et al: Manual versus powered tooth brushing for oral health. The Cochrane Database of Systematic Reviews 2005 Issue 2.
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