This alert highlights some of the key health care conclusions and their implications for practice as published in The Cochrane Library, Issue 3 - 2006


Acupuncture can help clear a chronic pain in the neck

There is moderate evidence that acupuncture can relieve chronic neck pain.
Between 26–71 percent of the adult population claims to have had at least one episode of neck pain or stiffness during their life. In many cases, this can last for months and has a large impact on life style, work and health care expenditure.
Acupuncture is one of the complementary medicines that is frequently used.
A group of Canadian-led Cochrane Review Authors completed a systematic review of the literature to see whether there is evidence that it works.
They found 10 trials, with a total of 661 participants, which investigated whether acupuncture alleviated neck pain.
In nine of the trials, participants had suffered neck pain for three or more months, while one included people who had had pain for at least six weeks.
To assess whether acupuncture reduces pain at all, some trials compared acupuncture with placebo treatments. In other trials, the researchers were trying to see how well acupuncture worked compared to another treatment.
Overall, people who received acupuncture reported better pain relief immediately after treatment than those who received placebo treatments such as TENS or laser that had the machines switched off, or acupuncture with the needles inserted in the wrong place. People who had acupuncture also reported that their pain went away to a greater extent than those who were just on a list waiting for treatment.
In one small trial, people who received acupuncture reported better pain relief in the short-term than those who received massage therapy.
There were no serious side effects reported in any of these trials.

" What we need now are some trials that include greater numbers of people and look at the long-term effect of the treatment," says lead Review Author Kien Trinh, at McMaster University, Hamilton, Canada.


Antihistamines cannot be recommended as a general therapy for non-specific coughs in children

Children with a cough that lasts more than 3-4 weeks and is not associated with an identifiable illness are sometimes given antihistamines.
In adults with chronic cough, antihistamines are recommended as an empirical treatment, but a systematic review of research failed to find evidence that it works for children.
Antihistamines do, however, have well known side-effects.
Balancing the small chance of benefit against the known risks, caused the researchers to conclude that; "antihistamines cannot be recommended as empirical therapy for children with chronic cough; very young children are particularly vulnerable to the adverse events."
There are two broad classes of antihistamines – the first generation H1 receptor antagonists ( eg. Diphenhydramine, Hydroxyzine, Chlorpheniramine, Brompheniramine and Clemastine ), and the second generation non sedating antihistamines ( Terfenadine, Astemizole, Loratadine and Cetirizine ).
The first generation drugs are less specific in their action and tend to have more side-effects.
One study found that Cetirizine reduces coughing within 2 weeks of starting treatment.

" There is a surprising lack of high quality evidence in this area, given that millions of children around the world have chronic coughs each year," according to lead Review Author Anne Chang. " What we need are well designed randomised controlled trials of antihistamines that are designed so that neither the child nor carers know which treatment is being given – this will help rule out any placebo effect that could confuse the results."


Taking calcium supplements during pregnancy halves the risk of pre-eclampsia

Worldwide pre-eclampsia accounts for 40,000 maternal deaths a year and can trigger premature birth which is extremely dangerous for the child.
A Cochrane Review of trials found that taking calcium supplements during pregnancy is a safe and cheap means of reducing the risk of pre-eclampsia.

“ We found no evidence of adverse effects, but we do need more research to find the ideal dosage of calcium ,” says lead Review Author Justus Hofmeyr, at the East London Hospital Complex, in South Africa.

This line of enquiry started after the chance observation that Mayan Indians in Guatemala have a low incidence of pre-eclampsia. One aspect of their lifestyle is that they soak their corn in lime before cooking and consequently have a high calcium diet.
Similarly pre-eclampsia rates in Ethiopia are low – again a culture that has a high calcium intake.
One theory is that high calcium levels in the blood stream may help muscles surrounding blood vessels to relax, which would tend to reduce blood pressure.

“ The reduction in pre-eclampsia, and in maternal death or severe morbidity, support the use of calcium supplementation, particularly for those with low dietary intake”, says Hofmeyr


Drugs given to stop nausea and vomiting after surgery help only a few people

Between 10-28% of people benefit from taking an anti-emetic drug to prevent nausea or vomiting after surgery, this means that if everyone was given the drug the majority of patients would be exposed to the risk of side-effects without gaining any benefit.
A Cochrane Review that included 737 studies involving 103,237 participants concludes that most patients given a drug to prevent nausea or vomiting after surgery will not benefit from it.
While 10 to 28% of people benefit, between 90 and 72% don’t.
But between 1 and 5% of experience side-effects that can include headache, sedation, or dry mouth.
Of the 60 drugs considered, nine were most effective: Droperidol, Metoclopramide, Ondansetron, Tropisetron, Dolasetron, Dexamethasone, Cyclizine, Ramosetron and Granisetron.
There was no evidence of difference between these drugs.


Amethocaine better than Eutectic Mixture of Local Anaesthetics ( EMLA ) at preventing pain from needle insertion in children

Local anaesthetic creams can make blood tests and intravenous drips pain free, but only if the creams are used properly.
A Cochrane Review comparing different anaesthetic creams, showed that both practitioners and children found Amethocaine better than EMLA.
When EMLA arrived on the market it gave the option of pain free blood tests for children, but it is only fully effective if the cream is applied for between one and three hours before the procedure.
In emergency situations this not feasible, and in the clinic it often does not occur The more recently introduced Amethocaine requires only 30-45 mins to reach full effect.

“ We found that Amethocaine was superior at reducing overall needle insertion pain experience by children not only when the full application times for each cream were used, but particularly when it was not possible to wait for the full time,” said lead Review Author Janice Lander, at the University of Alberta, in Edmonton, Canada.

The researchers were not, however, able to say whether either cream was better than the other at enabling a practitioner to insert a needle.


Don’t other with intravenous rehydration for diarrhoea – oral rehydration works just as well

In wealthy countries it is fashionable to prefer intravenous therapy over oral rehydration therapy.
A Cochrane Review however, has shown that oral rehydration therapy is just as effective as intravenous therapy.
The World Health Organization ( WHO ) estimates that in low-income and middle-income countries about 1.8 million children below the age of five years die of diarrhoea each year.
Almost 50% of these deaths are due to dehydration and most affect children less than one year of age. Children in high-income countries are not exempt. In the USA, for example, each year roughly 22 to 38 million episodes of diarrhoea occur among the 16.5 million children under the age of five years. Diarrhoea accounts for an estimated 2.1 to 3.7 million physician visits per year and 9 to 10% of all hospital admissions.
The issue is how best to provide these children with fluids and salts – intravenous therapy or oral rehydration therapy ?
Despite the fact that the American Academy of Pediatrics and the Centers for Disease Control and Prevention ( CDC ) recommend oral rehydration therapy, pediatricians in North America tend to use intravenous therapy.
By studying the data from 18 trials, nine of which took place in high income countries, a group of Cochrane researchers found that for every 25 children treated with oral rehydration therapy, only one would need to move on to intravenous therapy. If the low osmolarity solution recommended by the WHO is used, then this drops to one in a hundred.
The Review Authors also point out that intravenous therapy is much more technically demanding, as the clinicians need to calculate flow rates, whereas with oral rehydration therapy the child’s thirst mechanisms will help to regulate intake.

“ It seems reasonable that children presenting for medical care with mild to moderate dehydration secondary to acute gastroenteritis should initially be treated with oral rehydration therapy. Should treatment fail, then intravenous therapy may be used, ” says senior Review Author, William Craig, at University of Alberta, in Edmonton, Canada.


Exercise helps control type 2 diabetes

People with type 2 diabetes mellitus who perform regular exercise improve their blood sugar control and have reduced body fat. This reduction in fat occurs even if they don’t loose weight, suggesting that some of the fat may have been replaced by muscle.
‘ Do exercise ’ is one of the recommendations give to people with type 2 diabetes, alongside advice about diet and medication.
By carefully analysing data from 14 randomised controlled trials that involved a total of 377 participants, the Cochrane Researchers managed to tease out the component of benefit that can be attributed to the exercise component.
Exercise decreased glucose levels in haemoglobin by 0 6%, enough to have a clinically significant benefit for the person. For someone with a diagnosed value of 9% who needs to reduce to 7%, this represents a simple way of making one third of the change.
The benefits were seen in as little as eight weeks from the start of exercise.
The sorts of exercise that could help do not need to be extreme. It could include cycling to work, using stairs instead of a lift, or deliberately parking far from the shops when going shopping and then carrying your goods back to the car.
Exercise can therefore be recommended as one of the way of managing type 2 diabetes and can help a patient use less, or maybe even totally avoid, medication.


Source: The Cochrane Library, 2006


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