This alert highlights some of the key health care conclusions and their implications for practice as published in The Cochrane Library, Issue 2 - 2006


Insecticide treated nets beneficial for pregnant women in malaria-endemic Africa

No more need for clinical trials. A systematic review of currently available literature has shown that insecticide treated nets ( ITNs ) reduces placental malaria, low birth weight, and abortions and stillbirths in women living in malaria affected regions of Africa. The benefit is most noticeable in women during their first two to four pregnancies, and the effect is seen if the ITNs are used by whole communities or by individual women.

“ The evidence is clear – no further trials of ITNs are needed in sub-Saharan Africa, instead efforts should focus on improving their availability to pregnant women,” says lead Review Author Feiko ter Kuile, from the Liverpool School of Tropical Medicine, UK.

There is a need, however, for further research in areas of the world such as Asia and Latin America where malaria is present, but at a lower level.
The Review Authors found only one trial that had been performed outside of Africa. This study from Thailand showed that ITNs reduced the amount of anaemia in women and reduced the numbers of babies dying before birth, but the nets did not appear to ward off other problems. Pregnant women are particularly susceptible to malaria, and approximately 50 million pregnant women are exposed to malaria each year. This places both mother and baby at risk. Despite this, only a handful out of 80 studies of ITNs were randomised trials that looked at the effect of the nets on pregnant women.

“ ITNs should be an integral part of strategies to prevent malaria in pregnant women living in areas of Africa where malaria is endemic,” say Gamble and ter Kuile.


Use Buprenorphine to assist opioid withdrawal

Buprenorphine is more effective than Clonidine at helping people withdraw from opioids. It probably has similar effect as Methadone, but withdrawal symptoms may resolve more quickly with Buprenorphine.
These are the conclusions of a Cochrane Library systematic review that studied published research on the relative effectiveness of various treatments, including Buprenorphine, Clonidine, and Methadone.
They found 18 studies, 14 of which were randomised controlled trials. The studies included a total of 1356 participants.
Comparing Buprenorphine with Clonidine: patients treated with Buprenorphine had less withdrawal symptoms, stayed in treatment for longer, and were more likely to complete treatments.
There was no measurable difference in side-effects, although more people dropped out of Clonidine treatment because of side-effects.
Comparing Buprenorphine with Methadone: there are less studies making this comparison, but the severity of withdrawal appears to be similar for the two treatments. Withdrawal symptoms tended to resolve more quickly with Buprenorphine, and people may be more likely to complete withdrawal with Buprenorphine treatment than with Methadone.

“ What we need to know now is the extent of rebound withdrawal after short periods of use of Buprenorphine and Methadone,” says lead Review Author Linda Gowing, in World Health Organization ( WHO ) Collaborating Centre for Research in the Treatment of Drug and Alcohol Problems at the University of Adelaide.


Immunotherapy for recurrent miscarriage: good in theory, poor inpractice

None of the immunotherapy regimens that have been suggested as ways of helping women who have recurrent miscarriages to have a successful pregnancy show significant differences when compared with control groups.
Up to two in every one hundred couples experience three or more miscarriages during the first three months of pregnancies. Most of these losses can not be explained, but some doctors and scientist have suggested that the problem may lie in the woman’s immune system.
The immune system removes foreign objects, such as bacteria and viruses, from the body.
The fetus, however, could also be considered as a foreign body, and there is on-going research trying to make sense of how it evades rejection. But one theory suggests that women who experience repeated miscarriages have immune systems that do reject their fetuses.
To test the theory, and hopefully provide a treatment, doctors have tried using a variety of medications that aim to suppress the woman’s immune system.
The Review Authors headed by T Flint Porter at LDS Hospital, Salt Lake City, performed a systematic review of currently published data, to see whether these immunological techniques were working.
They found that neither of the two most common treatments ( immunization with paternal leukocytes or with intravenous immune globulin ) improved the live birth rate in women with unexplained recurrent miscarriage. Both are expensive and have potential serious side-effects and the Review Authors conclude that women should no longer be offered these treatments.

“ Women should be spared the pain and grief associated with false expectations that an ineffective treatment might work,” says Porter.

Furthermore, these researchers say that some of the immunological laboratory tests which have previously been used to justify immunotherapies have no predictive value for pregnancy success. These tests should therefore be abandoned.


Inhaled corticosteroids are better than sodium Cromoglycate in asthma control

In both children and adults with chronic asthma, inhaled corticosteroids help the lung to function more normally, and help control asthma more successfully, than sodium Cromoglycate.
Inhaled corticosteroids and sodium Cromoglycate are both used to help people with asthma.
Sodium Cromoglycate is believed to have a low risk of causing long-term side effects, but despite anxieties relating to routine use of steroids, the use of inhaled corticosteroids has steadily increased since the 1990s.
While they are both known to work, there has previously been a debate as to whether one is superior to the other. By pooling data from randomized controlled trials that directly compared the effects of inhaled corticosteroids and sodium Cromoglycate the Cochrane Review Authors could assess the relative benefits of each.
They considered measures of lung function, asthma control and the use of general healthcare services such as GPs and hospitals.
Their conclusion was that inhaled corticosteroids controls asthma better than sodium Cromoglycate and that it also leads to improved lung function. They were, however, unable to decide whether there were differences in side-effects as most of the trials ran for too short a time to assess long-term outcomes.

“ The superiority of inhaled corticosteroids over sodium Cromoglycate appears to increase when patients use moderate doses of inhaled corticosteroids, compared with when low doses of inhaled corticosteroids are used,” says lead Review Author James Guevara, at the University of Pennsylvania School of Medicine in Philadelphia.

The Review Authors believe there is little need for further research comparing the effectiveness of these two drugs, although some research may help clarify differences in side effects and the use of healthcare services.


Uncertainty over – give antibiotics in exacerbations of COPD

People with chronic obstructive pulmonary disease ( COPD ) often experience short term worsening and aggravation of their symptoms. To date, there has been conflicting evidence as to whether these exacerbations should be treated with antibiotic therapy.
A new systematic review now concludes that they should be used. The researchers found that antibiotics reduce the risk of dying from the attack by 77%, decreases the risk of treatment failure by 53% and decrease the risk of developing pussy sputum by 44%.
There is, however, a small increase in the risk of developing diarrhoea.
Many people question whether antibiotics should be used to combat exacerbations of COPD.
The uncertainty stems from the growing desire to use antibiotics only when necessary, combined with the recognition that up to one third of exacerbations of COPD have are not caused by infections, and some others are due to viral infections. A large number of trials have been conducted to try and address this situation, but a simple comparison suggests that the data is contradictory.
To clarify the situation the Cochrane Review Authors performed a systematic review of available data, and identified 11 trials involving 917 patients.

“ The review showed clearly that antibiotic therapy, regardless of which antibiotic was used, reduced the risks involved in an exacerbation, and as might be expected, the effects is greatest in patients with more severe disease,” says lead Review Author Felix Ram, at Massey University in Auckland, New Zealand.


Three herbal medicines for low-back pain

Randomised controlled trials show that extracts of Devils’ Claw ( Harpagophytum procumbens ), White Willow Bark ( Salix alba ) and Cayenne ( Capsicum frutescens ) all reduce low-back pain more than placebo.
Devils’ Claw and White Willow Bark also compare well with conventional medicine.
Back pain affects up to 85% of the population. Since a large proportion of patients with chronic low-back pain use complementary and alternative medicine, the Cochrane Review Authors conducted a systematic review to see if there was scientific evidence indicating that these medicines work.
They identified ten different randomised controlled trials that had involved 1,567 patients aged 18 years and older, who were suffering from acute ( less than one month ) or chronic ( longer than three months ) non-specific low-back pain. These studies assessed the effectiveness of three different herbal medicines.
Devils’ Claw ( Harpagophytum procumbens ), known for its anti-inflammatory and analgesic qualities, in a standardised daily dose of 60 mg Harpagoside, reduced pain to the same degree as 12.5 mg of the anti-inflammatory medication Rofecoxib ( Vioxx ).
White Willow Bark ( Salix alba ), used to relieve pain and lower fever, in standardized daily doses of 120 mg and 240 mg Salicin, reduced pain more than a placebo, and a dose of 240 mg was as effective as 12.5 mg of Rofecoxib.
Cayenne ( Capsicum frutescens ), which has pain blocking qualities and increases the flow of blood at the areas where it is applied, producing warmth on the skin surface, was tested in the form of a plaster; it reduced pain more than a placebo, and to the same degree as the homeopathic gel Spiroflor SLR.
The Review Authors do, however, add a note of caution.

“ Although short term trials show good results, we have no evidence to indicate they will definitely be safe or effective if used over a long period of time,” says lead Review Author, Joel Gagnier, at University of Toronto.


Acupuncture can bring some relief from chemotherapy induced nausea and vomiting

People undergoing chemotherapy often experience nausea and vomiting, but stimulating acupuncture points using electro acupuncture can reduce the incidence of vomiting on the first day of chemotherapy.
Electro acupuncture has not been studied for nausea or for vomiting on subsequent days.
Various conventional medicines have been developed to help reduce the amount of nausea and vomiting experienced by patients undergoing chemotherapy. These include 5-HT receptor antagonists such as Dolasetron, Granisetron and Ondansetron as well as Dexamethasone.
Despite this range of possibilities many people still feel and are very sick. This in itself can impair a person’s quality of life, lead to emotional distress and aggravate cancer-related symptoms such as lethargy and weakness.
The Cochrane Review Authors performed a systematic review to see whether any of the various modes of acupuncture could bring relief.
Manual acupuncture: involves inserting needles into specific ‘points’ around the body and does not involve the use of electricity. This did not reduce symptoms of nausea or vomiting on the first day. It was not studied for subsequent days.
Electro acupuncture: involves applying electrical stimulation to inserted needles. This reduced first-day vomiting, but was not studied for nausea or long-term symptoms. While patients in all the electroacupuncture studies also received antiemetic drugs along with the acupuncture, no studies used the most modern drugs by today's standards.
Acupressure: involves pressing with fingertips on acupuncture points. This reduced first day nausea, but did not reduce vomiting.

“ Acupuncture-point stimulation by any method is believed to be safe, and has minimal side effects. All the studies were done in patients who were using antiemetic drugs, so patients wanting to use acupuncture or acupressure should only considering using it alongside modern antiemetics,” says lead Review Author Jeanette Ezzo, Research, at James P. Swyers Enterprises, Baltimore.

The studies show that treatment it is best given before symptoms start and that electro acupuncture benefits last about eight hours; acupressure about two hours.

“ Research still needs to answer the question whether electro acupuncture given before chemotherapy offers additional relief on top of modern antiemetics. Only then will we know whether electro acupuncture might help those who still get sick even using the best medications” says Ezzo.


Source: The Cochrane Library, 2006


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